miiB 


BROMINE 


lOSPITiL  MlRil  ITl]. 


University  of  California. 


THE  MEDICAL  LIBRARY 

V .  J  .    I'M  )  r  H  a  K  A  r  I ).   m  .  i  >. 

or  San   Francisco. 


j     PRESENTED  BY  MES.  AND  MISS  POURGEAUD.      I 
i  ri:nii(M:y.  i<s:.-,.  \ 

^. __ . . ^ ^ 


A    REPORT 

ON 

HOSPITAL   aA^aREl^E, 

ERYSIPELAS  AND  PYtEMIA, 


AS    OBSERVED   IN   THE 


DEPARTMENTS  OF  THE  OHIO  AND  THE  CUMBERLAND, 


WITH  CASES  APPENDED. 


BY    M.    GOLDSMITH, 

Surgeoa  U.  S.  V. 


PUBLISHED  BY  PERMISSION  OF  THE  SURGEON  GENERAL  U.  S.  A. 


LOUISVILLE: 

BRADLEY  i:  GILBERT,  CORNER  OF  THIRD  AND  GREEN  STREETS. 


1863. 


Ki" 


OUHii 


REPORT 


Louisville,  Ky.,  Sept.  1st,  18G3. 
To  Brig.    Gen.   W.  A.  Haimnondj  Surg.  Gen.    U.  S.  A.,  Wush- 

ingto7i,  B.  C: 
Sir— 

The  investigations  whicli  have  been  conducted  in  this 
city  in  relation  to  hospital  gangrene,  erysipelas,  ichorrhaemia, 
thrombus,  metastatic  abcess  (pyfemia,)  diphtheria,  and  gan- 
grenous scarlatina,  have  had  for  their  objects  to  ascertain  : 

First,  the  nature  of  the  causes  operating  to  the  production 
of  the  diseases  ;  Secondly,  the  nature  of  the  process  set  in 
motion ;  Thirdly,  the  prophylactic  and  curative  agents. 

The  affections  just  named  are,  in  some  of  their  aspects,  so 
intimately  united  on  the  points  touched  in  these  investigations 
that  it  is  impossible  to  disunite  them  for  the  purpose  of  de- 
scription. 

The  opportunities  presented  in  the  Military  Hospitals  of  this 
city  for  the  study  of  some  of  these  diseases  have  been  great, 
especially  so  in  regard  to  hospital  gangrene.  For  the  study 
of  diphtheria  and  scarlatina,  except  in  connection  with  wounds, 
the  occasions  have  not  been  numerous  in  these  hospitals,  the 
cases  having  been  isolated  and  few.  Indeed  more  cases  have 
occurred  in  private  than  in  public  practice.  Enough,  how- 
ever, have  been  observed  to  justify  the  conclusions  expressed 
in  the  following  pages.  The  report  of  the  cases  of  scarlatina 
and  diphtheria  will  form  the  subject  of  a  separate  paper. 

Hospital  gangrene,  erysipelas,  gangrenous  diphtheria,  and 
scarlatina,  viewed  as  local  diseases,  present,  on  careful  study, 
many  points  of  resemblance  ;  nor  are  they  unlike  in  the  con- 
stitutional states  wedded  to  them.  These  resemblances  are 
marked. 


4  A   REPORT   ON 

111  diplitlieria  we  notice  the  transformation  of  tlie  exudate 
into  a  difHaeut  pulp,  the  erosion  of  the  subjacent  tissues,  and 
tlie  exuding  of  erosive  sero-purulent  fluid,  excoriating  the  skin 
and  mucous  membranes.  In  scarlatina,  we  observe  the  pro- 
duction of  sloughing,  or  ulcerous  surfaces,  exuding  also  cor- 
rosive sero-purulent  discharges.  Both  diseases  evolve  a  dis- 
gustingly putrid  odor.  Hospital  gangrene  always  presents 
pulpy,  diffluent  sloughs ;  exudes  thin  sero-purulent  discharges, 
corroding  the  skin  where  they  overflow  the  confines  of  the 
sore ;  and  emits  a  pungent  putrid  odor.  Erysipelas,  when  it 
runs  on  to  the  destruction  of  the  cellular  tissues,  is  attended 
with  like  phenomena. 

Erysipelas  and  hospital  gangrene  would  seem  to  be  cognate : 
and  although,  in  some  of  their  clinical  aspects,  they  do  not 
show  a  great  similarity,  yet  a  careful  study  of  the  fallowing 
columns,  setting  forth  the  points  of  similarity  and  dissimilar- 
ity, will  convince  the  reader  that  they  are  more  akin  than  ap- 
pears at  the  first  glance  : 


ERYSIPELAS. 

1st.  Attacks  skin  and  cel- 
lular planes  (succulent  tissues.) 

2d.  Does  not  readily  in- 
volve tendons,  fascise,  &c.,  (dry 
tissues.) 

Bd.  Spreads  along  the  skin 
and  cellular  planes. 

4th.  In  the  cellular  variety 
presents  necrosis  of  cellular 
substance,  in  diffluent  sloughs. 

5th.  "When  attended  with 
necrosis  of  the  cellular  tissue, 
exudes  corrosive  fluids.  The 
yellowish  fluid  produced  in  the 
phlegmonous  variety  contains 
uo   pus   or  other  cells;    the 


HOSPITAL    GANGRENE. 

1st.  Attacks  skin  and  cel- 
lular planes  (succulent  tissues.) 

2d.  Does  not  readily  in- 
volve tendons^  fasciae,  kc.y  (dry 
tissues.) 

3d.  Spreads  along  the  skin 
and  cellular  planes,  most  read- 
ily and  rapidly. 

4th.  In  all  tissues  which  it 
attacks  presents  pulpy,  difflu- 
ent sloughs,  (except  in  bones  ?) 

5.th.  Exudes  corrosive  sero- 
purulent  discharges,  excoria- 
ting the  skin.  The  yellowish 
fluid,  which  can  be  pressed 
out  of  gangrenous  sloughs  and 
soresj  contains  no  pus  or  otUei 


HOSPITAL   GANGRENE,   ERYSIPELAS,   AC.  5 

constituents  seem  to  be  fine  cells ;    the  constituents    seem 

granular  matter,  the  debris  of  to  be  fine  granular  matter,  the 

connective  tissue,  and  a  few  debris    of   connective    tissue, 

fibres  of  inelastic  fibrous  tis-  and  a  few  fibres  of  inelastic 

sue.  fibrous  tissue. 

Gth.     In  the  cellular  variety,  6th.     Emits  putrid  odors, 
emits  putrid  odors. 

7th.  Is  contagious  and  in-  7th.  Is  contagious  and  in- 
fectious, fectious. 

8th.  Is  frequently  compli-  8th.  Is  frequently  compli- 
cated with  thrombus.  cated  with  thrombus. 

9th.     Leads  occasionally  to  9th.      Leads     almost     con- 

ichorrhasmia.  stantly  to  ichorrhremia. 

10th.  Is  producible  by  in-  10th.  Is  producible  by  in- 
oculation with  putrefying  an-  oculation  with  putrifyiug  ani- 
imal  matter,  as  well  as  some  mal  matter,  as  well  as  by  some 
of  the  the  gaseous  products  of  of  the  gaseous  products  of 
putrefaction.       '  putrefaction. 

11th.  Arises  in  over-crowd-  Hth.  Arises  in  over-crowd- 
ed and  ill-ventilated  wards.  ed  and  ill-ventilated  wards. 

12th.     The  empirical  reme-  12th.     Empirical    remedies 

dies  addressed  to  the  constitu-  addressed  to  the  constitutional 

tional  state  are:    Tinct.  mur.  state  are:    Tinct.   mur.  ferri., 

ferri,    quinine,    alcohol,    etc.,  quinine,    alcohol,    etc.,    (anti- 

(antiseptics.)  septics.) 

13th.     Local  remedies  are :  13th.     Local  remedies  are  : 

iodine,   creosote,    tinct.    mur.  nitric    acid,     creosote,     chlo- 

ferri.,   sulph.  ferri.,  etc.,   (an-  rides,  charcoal,    &c.,  (antisep- 
tiseptics.) 


tics. 


In  the  present  state  of  our  knowledge,  we  regard  the  local 
manifestations  of  erysipelas,  of  scarlatina,  and  of  diphtheria, 
as  being  preceded  by  and  as  depending  upon  certain  blood 
states.  In  this  aspect  some  resemblance  is  noticeable  :  all 
three  of  these  diseases  seem  to  have  their  characteristic  ex- 
pression on  the  tegumentary  surfaces. 

Erysipelas  is  no  unfrequent  complication  of  both  scarlatina 


6  A    REPORT   ON 

and  diplitlieria.     They  are  all  adynamic  diseases,  and  present 
to  cliemical  examination  analogous  changes  in  the  blood. 

Of  the  causes  which  operate  in  producing  erysipelas,  this 
much  is  known  :  Erysipelas  is  often  the  product  of  dissecting 
wounds — of  wounds  received  in  skinning  diseased  cattle,  or  in 
skinning  the  putrefying  carcasses  of  those  killed  by  accident. 
It  is  often  seen  to  result,  in  the  form  of  puerperal  peritonitis, 
from  the  infection  upon  the  hands  of  the  midwife,  as  in  the 
historical  German  cases.  It  is  often  associated  with  injuries 
and  diseases  of  the  bones,  especially  with  caries,  a  disease  re- 
markable for  the  persistent  fetor  of  the  discharges.  Indeed  all 
that  is  known  with  regard  to  the  artificial  production  of  erysip- 
elas may  be  summed  uj>  in  the  agency  of  putrefying  animal 
matter. 

Erysipelas,  too,  seems  to  be  engendered  in  over-crowded  and 
ill-ventilated  apartments,  reeking  with  foul  emanations  of  the 
human  body;  in  rooms  receiving  exhalations  from  drains  and 
cess  pools,  especially  from  the  former.  It  is  producible  by 
miasm  emanating  from  the  bodies  of  those  having  the  disease. 
The  bodies  of  those  having  erysipelas,  in  some  of  the  worst 
epidemics  of  the  disease,  have  been  known  to  emit  a  putrid 
odor. 

The  bodies  of  those  who  die  pass-  quickly  into  putrefaction ; 
and  in  the  blood  of  such,  there  is  often  found  lactic  acid,  a 
product  of  putrefactive  decomposition.  The  whole  drift  of 
testimony  goes  to  show  that  erysipelatous  diseases  are  more 
or  less  connected  with  putrefactive  processes;  and  although  it 
may  not  be  possible,  in  the  present  state  of  our  knowledge,  to 
establish  the  precise  relation  between  the  two,  enough  is  known 
to  make  it  certain  that  an  intimate  relation  exists. 

Of  the  causes  which  produce  hospital  gangrene,  this  much 
is  known  :  Hospital  gangrene  arises  spontaneously  in  wards 
where  the  wounded  are  croAvded  together — where  the  wards, 
are  filled  with  the  stench  of  traumatic  profluvia,  and  receive 
the  air  of  sewers  and  cellars."^ 


4  beg  leaTe  to  interpolate  here  an  extract  from  a  report  made  by  me  to 


the 


HOSPITAL   GANGRENE,   ERYSIPELAS,   iC.  7 

It  is  produced  by  inoculation ;  and  there  is  reason  to  believe 
that  it  is  producible  by  keeping  the  putrid  flesh  of  healthy 
animals  in  contact  with  a  wounded  surface.  The  poison 
spreads  through  the  medium  of  the  atmosphere,  and  adheres 
with  great  endurance  and  tenacity  to  fomites.  That  the  gan- 
grenous process — the  spread  of  the  gangrene — is  propagated 
by  the  ever  produced  new  gangrenous  matter,  is  obvious  to  the 
most  superficial  examination^ 

As  to  the  mode  of  operation  of  the  agents  producing  erysip- 

Surgeon  General  in  regard  to  the  indigenous  production  of  hospital  gangrene  in 
the  hospitals  at  Nashville:  "I  find  that  in  Hospital  No.  8  there  have  occurred, 
according  to  the  best  evidence  in  reach,  thirty-eight  (38)  cases  of  hospital  gan- 
grene, of  indigenous  origin  ;  meaning,  hy  indigenous  origin,  those  cases  not 
produced  by  infection,  as  where  a  man  having  been  brought  into  a  ward  with 
hospital  gangrene  imparts  the  gangrenous  process  to  the  wounds  of  other  men. 

The  facts  are  briefly  these  : 

1st.     All  of  the  cases  occurred  in  AVard  No.  1. 

2d.  All  the  cases  occurred  in  the  row  of  beds  next  the  windows  opening  on 
the  alley. 

3d.  All  the  cases  occurred  prior  to  the  24th  of  April,  or  during  the  time  when 
the  external  atmosphere  was  colder  than  that  of  occupied  houses,  closed  cellars, 
or  underground  drains. 

4th.  The  cellar  under  the  hospital  had  passing  beneath  it,  and  opening  into 
it  by  several  apertures,  the  common  sewer  of  that  part  of  the  city. 

5th.  The  soil  pipes  from  the  privies  of  the  several  wards  traversed  this  cel- 
lar, and  emptied  without  a  trap  into  the  common  sewer. 

6th.     This  soil  pipe  is  made  of  tin  and  leaks  badly. 

7th.  In  wet  weather  the  cellar  bottom  is  overflowed  by  the  contents  of  the 
soil  pipe  and  sewer. 

8th.  This  cellar  has  but  two  openings,  one  in  the  front  of  the  building  and 
one  in  the  alley. 

9th.     The  alley  is  long,  narrow,  and  the  hospital  buildings  and  barracks  high. 

10th.  The  area  of  the  adjacent  building  receives  the  drainings  of  the  garbage 
of  its  kitchen,  and  this  area  forms  a  part  of  the  alley. 

11th.  Ward  No.  1  derives  its  ventilation  almost  entirely  from  windows  open- 
ing on  the  alley.  On  the  opposite  side  there  is  but  one  opening,  a  door  leading 
to  a  hall  which  has  no  window.  On  the  end  next  the  street  there  are  but  three 
windows. 

12th.  The  prevailing  winds  during  cold  weather  sweep  the  street  in  the  front 
of  the  building,  leaving  the  atmosphere  in  the  alley  almost  undisturbed. 

13th.  The  emanations  from  the  area  of  the  adjoining  building,  as  well  as 
those  from  the  cellars  of  the  Barracks  and  Hospital  are  most  oflFensive  at  all 


8  A   REPORT   ON 

elas  and  hospital  gangrene,  but  little  is  known  accurately.  The 
erysipelatous  virus,  waiving  all  considerations  as  to  its  person- 
ality, seems  to  operate  through  the  atmosphere,  and,  accord- 
ing to  traditional  views,  gains  entrance  into  the  blood  through 
the  respiratory  organs.  This  subject  needs  reinvestigation, 
for  there  are  some  facts  which  seem  to  militate  against  this 

received  view  of  the  matter.     These  facts  are  the  following : 

» 

times,  and  are  most  disgustingly  perceptible  in  tlie  evening  when  the  external 
atmosphere  begins  to  grow  cool. 

14th.  The  cases  of  hospital  gangrene  did  not  recur  after  the  weather  grew 
warm — when  the  outer  air  was  warmer  than  the  air  in  the  cellars  or  sewer. 

15th.  The  buildings  on  the  opposite  side  of  the  street  (the  alley  running 
through  only  one  square,)  prevented  any  wind  from  traversing  the  alley  below 
the  second  story. 

In  the  early  part  of  the  season  one  patient  was  brought  into  the  ward  with 
hospital  gangrene.  In  a  few  hours  six  other  cases  were  developed  in  wounded 
men  lying  adjacent  to  him.  The  disease  did  not  spread,  and,  with  the  termina- 
tion of  these  cases,  disappeared  for  a  season.  Whsn  it  broke  out  again,  it  at- 
tacked those  who  had  come  into  the  Hospital  without  any  appearance  of  a  gan- 
grenous condition  of  their  wounds  at  the  time  of  admission. 

It  will  appear,  from  the  facts  jelated,  that  the  miasms  evolved  by  putrifying 
.animal  matters  in  the  cellar  of  the  hospital,  and  perhaps  in  the  area  of  the  bar- 
racks, were  given  oif  at  all  seasons  ;  that  just  during  the  season  when,  from  t]ie 
relations  of  the  temperature,  the  atmosphere  of  the  cellar  and  (his  upward  cur- 
rent would  enter  the  ward  most  constantly  [i.  e.  when  it  was  necessary  to  heat 
the  ward  with  stoves,)  the  cases  of  gangrene  occurred ;  that  they  occurred  in 
just  that  locality  in  which  the  miasm  of  the  cellar,  in  least  dilution,  would 
impinge  upon  the  patients  ;  and  that  as  soon  as  those  relative  conditions  of  the 
temperature  obtained  in  which  the  miasm  of  the  cellar  would  flow  downwards 
(i.  e..  when  the  external  air  was  warmer  than  that  of  the  cellar,)  and  when, 
from  the  extinction  of  fires,  no  air  was  drawn  in  at  the  windows,  the  disease 
ceased. 

The  testimony  of  the  Surgeon  having  the  ward  and  cases  in  charge  is  all  the 
more  valuable  for  that  he  did  not  anticipate  or  interpret  the  facts.  The  Sur- 
geon noticed  without  peculiar  concern  the  occurrence  of  the  affection,  and,  as  he 
expressed  himself  to  me,  supposed  that  by  some  singular  chance  "those  pa- 
tients having  the  lowest  vitality  were  placed  in  that  row  of  beds."  And  he 
marveled  greatly  that  the  cases  should  occur  just  where  the  ventilation  was  best, 
because  the  windows  on  the  alley,  being,  the  only  available  inlets  for  air  in  the 
ward,  were  opened  diligently  four  times  a  day,  and  some  part  of  each  window 
was  kept  open  all  the  while.  I  think  that  the  records  of  surgery  do  not  afford 
a  more  unique  or  striking  example  of  one  of  the  methods  of  the  production 
of  hospital  gangrene." 


HOSPITAL   GANGRENE,   ERYSIPELAS,   &C.  0 

It  is  found  that  those  recovering  from  erysipelas  of  the  head 
and  fiice  are,  after  desquamation  of  the  face,  peculiarly  liable 
to  new  attacks  on  exposure  to  the  miasm  in  infected  wards, 
and  that  this  liability  to  the  disease  is  prevented  by  coating 
the  face  with  a  tincture  of  iodine,  (which  process  detaches 
an  epithelial  coating,)  or  by  constant  embrocations  with  gly- 
cerine, or  with  castor  oil,  with  collodion,  &c.  Erysipelas,  at- 
tacking the  face,  respects,  in  its  first  invasion,  the  parts  which 
by  accident  are  covered  by  such  coatings  as  are  made  with 
adhesive  plaster.  It  hardly  ever  begins  in  parts  covered  by  hair 
and  sebaceous  matter,  as  the  scalp. 

If  the  poison  of  erysipelas  acts  from  the  blood,  it  is  difficult 
to  understand  why  it  so  constantly  selects  the  face  as  the  be- 
ginning point,  and  yet  commencing  in  the  face  extends  so 
rapidly  to  the  scalp,  and  neck,  and  thorax. 

Any  part  of  the  skin,  provided  only  that  it  is  abraded,  may 
be  invaded  by  erysipelas.  That  of  the  trunk  or  extremities  is 
attacked,  provided  there  is  an  ulcer  or  wound.  If  a  man  has 
caries,  or  necrosis,  or  hospital  gangrene,  or  any  disease  com- 
monly associated  with  erysipelas,  the  latter  attacks  the  skin 
at  the  site  of  the  original  disease.  Kow  a  morbific  agent  in 
the  blood  is  said  to  attack  those  tissues  or  parts  of  the  body 
which  have  a  supposed  affinity  for  the  poison,  a  susceptibility 
or  sensitiveness  to  it:  as,  for  instance,  ergot  impresses  the 
uterus;  phosphorus,  the  jaw;  nitrate  of  silver,  the  skin  and 
kidneys ;  but  it  is  not  known  that  any  producible  condition  of 
these  organs  renders  them  any  more  sensitive  to  the  matters  cir- 
culating in  the  blood.  The  precipitation  of  the  silver  on  the 
particular  tissues  seems  to  depend  upon  original  endowments 
of  the  parts.  How  is  it  with  the  poison  of  erysipelas  ?  The 
theory  runs  that  it  enters  the  blood,  and,  by  the  operation  of 
a  sort  of  elective  affinity,  it  attacks  the  skin  of  the  face,  and 
respects  the  skin  of  all  other  parts  in  relation  to  points  of 
original  invasion.  True,  beginning  in  the  face,  it  may  spread 
to  other  parts,  but  it  (idiopathic  erysipelas)  rarely  beams  at  any 
other  point  except  as  mentioned  hereafter.     The  non-parturient 


10  A   REPORT   ON 

woman  does  not  have  erysipelatous  metritis  or  peritonitis, 
however  much  she  is  exposed  to  the  inhalation  of  the  miasm ; 
if  she  has  erysipelas  at  all,  she  gets  it  on  the  face,  like  other 
people.  Men  and  non-parturient  women  breathing  the  miasm 
get  the  disease  on  the  face,  not  on  the  trunk  or  extremities. 
But  let  a  woman  give  birth  to  a  child,  and,  during  the  par- 
turient state,  let  her  be  exposed  to  the  miasm,  and  straightway 
she  gets  puerperal  peritonitis.  During  the  non-parturient 
state  a  hundred  women  may  be  exposed  to  the  miasm,  and  not 
five  per  cent,  will  have  erysipelas  of  the  face  ;  and  yet,  if  one 
hundred  parturient  women  are  exposed  to  the  miasm,  how 
many  would  escape  puerperal  peritonitis?  "Would  twenty 
per  cent.  ?  N"ow  why  is  the  parturient  woman  more  influenced 
by  the  miasm  ?  Certainly  not  by  reason  of  any  blood  state  ; 
for  all  the  blood  changes  peculiar  to  her  condition  have  their 
climax  on  -her  delivery,  and  exist  in  large  development  an- 
terior to  her  delivery.  The  miasm  seems  potent  not  prior  to 
but  after  delivery,  when  the  puerperal  blood  states  are  in  the 
process  of  involution.  What  is  the  pathological  condition  of 
the  parturient  woman  precisely  coeval  with  the  period  in  which 
she  is  so  exceedingly  liable  to  the  invasion  of  erysipelas  ? 
Just  this :  her  uterus  is  stripped  of  its  lining  epithelium ;  the 
internal  surface  of  the  uterus  is  like  apiece  of  skin  stripped  of 
its  epidermis.  After  this  epithelial  covering  is  reproduced,  the 
parturient  woman  is  no  longer  any  more  liable  to  the  invasion 
of  erysipelas  than  she  was  before  she  became  pregnant. 

Again :  expose  a  hundred  men  to  the  miasm  of  erysipelas  ; 
a  certain  number  will  have  erysipelas  of  the  face,  the  disease 
always  commencing  in  the  eye-lid,  in  the  alse  of  the  nose,  or 
behind  the  ear.  The  disease  commences  in  no  other  part  of 
the  body;  it  does  not  attack  the  trunk  or  extremities.  But  if 
wounds  or  abrasions  exist,  the  erysipelas  no  longer  selects  the 
face,  but  attacks,  without  discrimination  of  region,  the  parts 
wounded  or  abraded — provided  only  that  the  parts  thus  wound- 
ed or  abraded  are  uncovered.* 

*I  here  ^erpolate  another  passage  from  my  report  to  the  Surgeon  Geueral  on 
the  indigenous  origin  of  hospital  gangrene  and  erysipelas: 


nOSPITAL   GANGRENE,   ERYSIPELAS,   iC.  11 

This  is,  at  least,  tlie  general  rule.  True,  that  wounded  men 
sometimes  get  the  erysipelas  in  the  face,  whilst  the  wounded 
parts  are  respected ;  and,  as  in  some  instances  observed  here, 
after  the  erysipelas  has  run  its  course  in  the  face,  the  wounded 
parts  have  become  involved.  Still  the  general  rule  is,  that,  in 
idiopathic  erysipelas,  the  disease  begins  in  the  face,  except  in 
children,  and  the  exception  is  a  pregnant  one.  Children  have 
idiopathic  erysipelas  in  the  extremities  almost  as  often  ais  in 
the  face,  but  this  liability  to  erysipelas  in  the  legs  of  children 
is  confined  to  the  period  of  long  clothes;  the  disease  no  long- 
er appears  idiopathically  when  the  children  are  weaned,  and 
advanced  to  short  clothes.  ^ 

Again:  those  who  have  had  erysipelas  of  the  face,  and  who 
have  just  recovered,  are,  as  is  well  known,  exceedingly  liable 
to  new  attacks,  relapses,  especially  in  hospitals,  l^ow  this 
liability  disappears — the  men  are  protected  by  coating  the 
face  with  tinct.  of  iodine,  or  by  frequent  application  of  gly- 
cerine, or  simple  cerate,  or  resin  ointment. 

"The  other  occurrences  which  I  wish  to  relate  were  observeil  at  Hospital  No. 
8.  The  building  is  five  stories  high,  and  consists  of  two  stores;  it  stands  upon 
the  corner  of  the  streets.  The  sides  of  the  building  fronting  on  the  streets  have 
windows  in  them.  The  other  sides  have  none,  except  one  in  each  ward  at  the  end, 
where  it  abuts  for  two  stories  upon  an  alley  or  area  about  six  feet  wide;  a 
hoistway  is  cut  from  the  lower  to  the  upper  ward  in  that  half  of  the  building 
under  consideration.  During  the  continuance  of  erysipelas  at  this  hospital,  all 
the  cases  occurred  in  the  upper  ward  of  this  side,  and  the  disease  continued 
unabated  until  the  glass  in  the  skylight  overhanging  the  hoistway  was  broken 
out,  so  as  to  allow  the  foul  air  ascending  from  the  lower  wards  to  pass  through 
the  roof;  cotemporaneously,  three  windows  were  opened  in  the  side  of  ths  ward, 
and  two  in  the  end. 

The  inmates  of  this  ward  were  mostly  and  during  a  part  of  the  time  exclu- 
sively wounded  men.  The  singular  fact  noticed  in  regard  to  the  cases  was  that 
the  erysipelas  in  no  case  attacked  the  wounded  parts.  It  always  attacked  the 
face.  Such  an  occurrence  demanded  investigation.  I  enquired  of  the  Surgeon 
if  he  pursued  any  peculiar  treatment.  The  Surgeon  in  charge,  who  was  stand- 
ing by  at  the  the  time,  remarked,  with  a  smile,  that  the  Assistant  Surgeon  in 
charge  of  the  erysipelas  ward  had  a  peculiar  and  uniform  way  of  dressing  a 
wound,  a  way  which  he  never  departed  from  ;  it  was  this  :  lie  always,  'after  hav- 
ing cleansed  the  ivound.  covered  it  over  completely  with  ung.  resina;  so  placed  as  to  ex- 
clude the  air  from  the  graiiulations  completely.  After  this  dressing,  warm  water  was 
applied  over  the  wounded  parts. 


12  A   REPORT   OK 

Furtlier:  all  the  known  blood  poisons — all  foreign  sub- 
stances tending  to  precipitation  in  certain  parts,  elimination 
by  certain  organs — seek,  if  the  habitual  destinies  of  the  sub- 
stances are  interfered  with,  vicarious  locations  or  secretions. 
Thus  uric  acid,  in  gout,  tends  to  certain  points,  e.  g.,  the  joints  ; 
now  if  the  deposition  of  uric  acid  or  its  compounds  at  the 
joints  is  interfered  with,  straightway  the  uric  acid  seeks  an- 
other nidus.  If  the  agent  producing  rheumatism  is  driven 
away  from  its  resting  place,  it  straightway  seeks  another.  If 
bone-earths,  redissolving  in  certain  bone  diseases,  fail  of 
elimination  by  the  kidneys,  they  are  deposited  in  the  lungs  or 
in  the  coats  of  the  stomach.  No  local  treatment  of  gout  or  of 
rheumatism  aborts  the  disease.  The  utmost  hope  of  topical 
treatment  is  palliation  of  pain,  or  of  local  pathological  pro- 
cesses. The  agents  here  are  known  and  recognizable  blood 
poisons.  The  local  affections  continue  because  of  the  contin- 
uous application  of  the  morbific  agent.  With  the  expurgation 
from  the  blood  of  the  agent,  with  the  drying  up  of  the  foun- 
tains from  which  those  poisons  flow,  the  local  diseases  cease — 
and  all  remedial  means  look  in  this  direction. 

The  records  hereto  appended  show  that  erysipelas  may  be 
interrupted  at  any  point  in  its  progress  or  development,  and 
that  any  such  interruption  does  not  produce  metastasis ;  nay, 
more,  it  shows  that  the  constitutional  state  not  only  is  not  ag- 
o-ravated  thereby,  but  that,  in  the  obsolescence  of  the  local  dis- 
ease, the  constitutional  symptoms  vanish. 

Further,  all  that  we  know  of  the  order  of  events  in  inocu- 
lable  diseases — as  vaccinia  and  hydrophobia — and  their  abor- 
tion, corresponds  with  what  we  claim  for  erysipelas. 

In  vaccination  we  have  a  period  of  incubation  of  about 
four  days;  at  the  end  of  this  time  there  is  some  elevation  of 
the  skin,  but  no  redness — this  corresponds  to  the  period  of  in- 
filtration. After  the  fourth  or  fifth  day,  inflammation  sets  up, 
and  coincidentally  the  symptomatic  fever.  If,  at  this  point,  the 
vaccinia  is  aborted  by  any  accident,  the  constitutional  state 
falls  with  it ;  nor  is  the  protective  agency  of  the  vaccination 
developed. 


HOSriTAL   GANGRENE,   ERYSIPELAS,   &C.  13 

May  it  not  be  possible  that  tbe  poison  of  erysipelas  acts  in 
tbe  same  way  ?  that  there  belongs  to  it  a  period  of  local  incu- 
bation— zymosis — corresponding  with  the  period  of  infiltration 
in  vaccinia  ?  that  then  the  inflammatory  stage  is  developed ; 
and  that  constitutional  infection  may  be  produced,  at  any  period 
intervening  between  the  first  contact  of  the  infectious  matter 
and  the  development  of  the  local  process,  as  well  as  after  the 
inflammatory  symptoms  are  developed  ? 

jSTow  if  the  ancient  dogma  is  founded  in  truth,  and  if  the 
miasm  of  erysipelas  gets  into  the  blood,  and  by  virtue  of 
hypothetical  affinities  precipitates  itself  upon  the  skin  of  the 
face,  as  nitrate  of  silver  does  upon  the  whole  skin,  and  as  ergot 
does  upon  the  uterus,  we  have  to  assume,  in  order  to  make 
the  dogma  coherent,  that  wound.s  endow  the  skin  of  the  ex- 
tremities with  a  new  order  of  affinities ;  that  the  puerperal 
state  of  the  uterus  endows  it  and  the  peritoneum  with  new 
sensibilities;  that  the  skin  on  the  legs  of  infants  has  afiinities 
that  disappear  with  age ;  that  the  coating  of  the  face  in  the 
adult  with  grease  destroys  its  affinities — and  all  this  in  the 
face  of  the  fact,  that  wounds,  the  puerperal  state,  age,  and  pro- 
tection, are  not  known  to  have  any  influence  upon  these  afiini- 
ties or  local  sensibilities  in  connection  with  measles,  or  scar- 
latina, or  small-pox,  or  with  other  diseases  affecting  the  skin  I 

Do  not  these  facts  c^uadrate  better  with  the  idea  that  the 
contagion  of  erysipelas  acts  rather  by  contact  with  the  skin  ? 
That  the  contagion,  floating  in  the  atmosphere,  attacks  the 
face  because  the  face  is  the  part  uncovered  ?  That  the  face  is 
attacked,  in  preference  to  the  hands,  because  of  its  thinner 
epithelium  and  more  superficial  vessels  ?  That  the  disease  at- 
tacks the  eye-lid,  the  alai  of  the  nose,  and  the  skin  behind  the 
ear,  because  just  precisely  here  the  epithelium  is  thinnest? 
That  it  avoids  the  hands  on  which  the  epithelium  is  thick  ? 
(Whoever  saw  erysipelas  attacking  the  unwounded  palm  of 
the  hand,  or  unwounded  sole  of  the  foot?)  "Would  it  not  be 
reasonable  to  suppose  that  desquamation  of  the  skin  or  its 
division  by  wound  or  ulceration — the  exfoliation  of  the  mater- 
nal surface  of  the  uterus — opened  the  parts  to  the  action  of 


14  A   REPORT    ON 

the  contagion  just  as  tlie  ^ame  conditions  would  open  tlie 
parts  to  tlie  action  of  medicine?  That  the  constant  exposure 
of  the  child's  legs  to  the  contact  of  air,  (or  that  perhaps  the 
fact  that  in  the  child's  body  there  are  not  yet  developed  those 
diiferences  in  the  thickness  of  the  epithelium  which  obtain 
later  in  life),  allows  the  contagion  to  act  with  equal  advantage 
upon  different  parts  of  the  body  ?  That  the  protection  of  the 
tender  and  thinly  covered  skin  of  those  just  recovering  from 
erysipelas  of  the  face  may  prevent  th.e  action  of  the  contagion, 
and  thus  give  immunity  to  relapses  ? 

In  all  this  I  do  not  claim  the  abnegation  of  the  traditional 
dogma,  but  I  think  the  considerations  here  urged,  and  the 
records  hereto  appended,  show  sufficient  ground  for  demand- 
ing of  thinking  men  the  re-investigation  of  the  accepted 
theory  that  they  show,  at  least,  that  the  increasing  gravamen 
of  some  of  the  diseases,  supposed  to  originate  in  blood  infec- 
tions, is  due  rather  to  the  retroactive  influence  of  the  local 
parts  of  those  diseases  than  to  an  increasing  quantity  or  inten- 
sity, or  to  a  growing  zymosis,  of  the  original  blood  poisons. 

Pyaemia  is  divided  into  two  conditions ;  that  is,  the  condi- 
tions formerly  expressed  by  this  term  are  now  known  to  be: 
first,  a  state  denominated  ichorous  infection — ichorrsemia — a 
condition  pronounced  commonly,  when  exquisitely  developed, 
by  frequent  rigors,  feeble  pulse,  loss  of  appetite,  colliqua- 
tive local  sweats,  a  fermentative  odor  of  the  breath,  pallor 
of  the  lips  and  face,  and  great  muscular  prostration;  second, 
metastatic  abscesses  and  inflammations,  produced  by  the  sof- 
tening and  detachment  of  thrombi  previously  formed. 

Both  of  these  states  may  or  may  not  be  complicated  with 
Icucocytosis,  primarily  or  secondarily'. 

The  first  of  these  conditions,  ichorniemia,  is  the  constitu- 
tional state  developed  with  the  greatest  rapidity,  most  rapidly 
leading  to  a  fatal  result,  and  connected  more  frequently  with 
gangrene  and  with  injuries,  especially  those  involving  bones. 

Thrombosis,  the  commencing  point  of  the  second .  class,  is 
frequently,  not  always,  associated  with  ichorrremia.  Both  of 
these  processes,  the  ichorriemic  and  the  thrombic  (pya^mic). 


HOSPITAL    GANGRENE,    ERYSIPELAS,   AC.  15 

are  connected  occasionally  with  tlic  more  serious  local  effects 
of  erysipelas,  as  abscesses  and  sloiigliing  of  the  cellular  tissue; 
on  the  other  hand,  erysipelas  and  hospital  gangrene  are  not 
necessarily  followed  by  ichorraemia,  although  but  few  cases  of 
hospital  gangrene  present  themselves  in  which  more  or  less 
of  ichornemia  does  not  exist,  at  least  during  the  advance  of 
the  gangrenous  processes. 

This  ichorous  infection  seems  to  depend  upon  the  presence 
of  putrid  matter  in  wounds,  in  suppurating  cavities  and  gan- 
grenous surfaces  or  excavations.  The  record  of  cases  will  show 
that  a  constant  correspondence  exists  between  fetid  discharges 
and  ichorous  infection.  In  all  the  cases  carefully  noted  in 
this  context,  it  has  been  observed  that  the  discharges  were 
fetid  jjrior  to  the  development  of  the  symptoms  of  ichorous 
infections.  The  fetor  may  have  been  noticed  for  variable 
periods,  but  was  always  noticeable  prior  to  the  constitutional 
symptoms.  Ichorous  infection  does  not  always  follow  upon 
fetor  of  the  discharges,  but  ichorous  infection  never  occurs 
where  the  discharges  are  not  fetid;  not  only  so,  but  in  all  of 
the  cases  recorded  it  will  be  seen  that,  as  soon  as  the  fetor  was 
corrected,  the  symptoms  of  the  ichorous  infection  began  to 
disappear,  and  that,  too,  with  a  rapidity  which  was  surprising 
to  all  the  observers. 

Again:  it  will  be  seen  that  relapses  took  place,  and  that 
relapses  were  coincident  with  a  return  of  the  fetor. 

The  constant  co-existence  of  the  putrescence  of  the  products" 
of  ulcerous  surfaces,  and  ichorous  infection — the  constant  pre- 
cedence of  the  former  in  point  of  time,  the  constant  disappear- 
ance of  the  latter  upon  the  disappearance  of  the  former,  point 
out  an  intimate  connection  between  the  two  events;  indeed, 
establishes  the  dependence  of  the  latter  upon  the  former. 
"What  the  peculiar  substance  is,  which,  getting  into  the  blood, 
gives  rise  directly  or  indirectly  to  the  ichorrfemia,  we  do  not 
as  yet  know.  Of  it,  we  know  this :  first,  that  it  is  developed 
during  the  putrefactive  decomposition  of  animal  matter; 
second,  that  it  is  not  pus  in  its  cells,  intracellular  fluid,  or 
intercellular  fluid,  (I  refer  to  normal  and  so  called  reproductive 


16  A   REPORT   ON 

pus) ;  tliird,  that  it  is  a  fluiil,  or  dissolved  in  a  fluid.  That  it  is 
developed  during  tlie  putrefactive  decomposition  is  made  prob- 
able by  tbe  following  facts :  ichorous  infection,  as  stated  above^ 
occurs  only  in  cases  where  this  process  is  going  on  ;  the  effects 
of  the  agent  disappear  upon  the  arrest  of  putrefaction  in  the 
wound;  the  influence  of  the  agent  is  destroyed  by  any  sub- 
stance which  arrests  putrefaction.  Further :  somehow  empiri- 
cal medicine  has  fallen  into  the  habit  (and  with  good  reason, 
doubtless)  of  employing  certain  remedies.  These  agents  have, 
traditionally  and  in  truth,  value  in  the  treatment  of  the  several 
affections.  All  that  we  know  of  this  treatment  is  summed  up 
in  these  empirical  remedies.     Let  us  examine  them. 

First,  as  to  erysipelas :  the  topical  remedies  known  to  be 
most  efficient  by  virtue  of  any  active  property  of  their  own, 
are,  tinct.  iodine,  tinct.  mur.  ferri,  creosote,  and  sulph.  ferri. 
These  substances  are  diverse  in  their  active  properties;  in 
what  does  creosote  resemble  iodine  or  iron  ?  They  agree  only 
in  this,  that  they  are  antiseptics,  that  they  break  up  the  pu- 
trescent actions.  Secondly,  as  to  hospital  gangrene  :  The  local 
remedies  growing  into  repute,  after  long  and  disheartening 
experience,  are  nitric  acid,  nitrate  of  silver,  acid  nitrate  of 
mercury,  arsenical  solution,  chlor.  of  soda,  and  the  actual 
cautery.  These  are  all  antiseptics.  They  agree  in  this,  and 
in  this  alone — that  they  break  up  the  putrescent  series  directly 
or  indirectly.  Thirdly,  as  to  pyaemia :  All  the  agencies  found 
to  be  useful  in  preventing  the  development  of  pyaemia  are  free 
openings  in  depending  positions,  drainage  tubes,  and  cleanli- 
ness. Some  use  has  been  made  of  injections  of  chlorinated 
water,  and  of  solutions  of  hyposulphite  of  soda  and  of  iodine. 
These  look  in  the  same  direction :  on  the  one  hand,  cleanli- 
ness, depending  openings,  and  drainage  tubes,  look  to  the 
easy  and  rapid  removal  of  the  discharges  of  wounds ;  and  on 
the  other,  iodine,  chlorinated  washes,  and  the  sulphites,  to  the 
arrest  of  putrefaction  in  animal  matter.  It  would  seem  a  lit- 
tle singular  that,  in  the  slow  and  gradual  growth  of  empirical 
medicine,  remedy  after  remedy,  selected  byj-)urcly  experimen- 
tal processes,  and  not  under  the  domination  of  any  theory  as 


HOSPITAL    GANGRENE,    ERYSIPELAS,    AC.  17 

to  the  diseases  in  question,  should  be  found  side  by  side  in 
common  use,  and  that  those  remedies  should  be  found,  how- 
ever diverse  they  are  in  their  other  qualities,  to  agree  with 
perfect  uniformity  in  one  common  quality,  unless  that  one 
quality  had  some  relation  to  the  special  nature  of  the  diseases 
or  the  causes  of  their  production. 

A  series  of  investigations  is  now  on  foot  seeking  to  dis- 
cover the  essential  agent,  if  one  exists,  which  sets  up  these 
diseases.  It  may  be  that  there  is  one  product  of  the  putrefac- 
tive decomposition  appropriate  to  the  production  of  each  of 
these  diseases.  It  may  be  that  the  putrilage,  or  some  of  its  as- 
sociate products,  exercises  a  catalytic  influence  in  the  produc- 
tion of  the  local  processes,  and  that,  the  putrid  fluids,  passing 
into  the  circulation,  exercise  a  direct  poisonous  agency,  or  set 
up  in  the  blood  analogous  processes.  It  is  probable,  for  the  re- 
sults thus  far  reached  point  in  this  direction,  that  peculiar 
alkaloids  are  produced  in  putrefactive  decomposition,  and  that 
one  or  more  of  these  are  the  active  agents.  "Whatever  the 
agents  are,  they  exist  to  some  extent  in  all  kinds  of  putrescent 
animal  matter. 

While  it  may  be  premature,  at  the  present  stage  of  the  in- 
vestigations which  I  am  engaged  in  making  under  your  orders, 
to  attempt  to  determine  the  agent  specially  concerned  in  the 
production  of  pyeemia,  this  much,  I  think,  can  be  stated  as 
probably  true : 

1st.  That  it  is  not  the  final  product  of  putrefactive  fermenta- 
tion. The  final  products  of  fermentation  or  putrefaction  difier 
from  the  initial  and  mediate  products.  As  in  the  fermentation 
of  starch  we  have  alcohol  and  vinegar,  so  in  the  putrefac- 
tion of  animal  tissues  we  have,  according  to  the  stage  of  the 
putrescent  motion,  differing  products.  So,  again,  according  to 
the  conditions  of  moisture,  heat,  and  access  of  air,  we  have 
putrefaction  going  on  with  diff'erent  phenomena  and  products. 
Who  has  fiiiled  to  perceive  the  difixsring  results  of  that  putre- 
faction which  takes  place  in  the  ordinary  process  of  macera- 
tion, in  the  cadaver  enclosed  in  a  metallic  coflin,  and  in  a  car- 
cass exposed  to  the  sun  ? 


18  V  A    REPORT    ON 

2d.  The  agent  will  probably  be  found  to  be  generated  most 
freely  in  the  initial  stages  of  putrefaction.  This  view  is  borne 
out  by  the  results  of  inj  ections  into  the  veins  of  animals.  Solu- 
tions of  putrid  pus,  which  do  not  evolve  ammoniacal  products, 
freely  produce  commonly  a  group  of  symptoms  more  allied  to 
ichorrffimia ;  while  solutions  of  highly  putrid  substances  com- 
monly produce  death  w^ith  great  rapiditj',  engendering  gangre- 
nous affections,  or  in  less  degree  producing  diarrhea,  vomiting, 
or  a  condition  allied  to  the  ammonisen^a  of  Jacksh.  The 
discharges  and  gangrenous  pulps,  so  far  noticed  as  connected 
with  ichorrsemia,  had  an  acid  reaction,  always  disappearing 
on  keeping  the  specimen  until  ammonia  was  developed  freely. 
At  present,  however,  nothing  definite  or  certain  in  this  rela- 
tion, other  than  the  meagre  facts  above  stated,  can  be  adduced. 
This  branch  of  the  subject  is  under  investigation  by  two  chem- 
ists of  ability,  one  here  and  one  at  Nashville. 

The  difference  in  the  resulting  symptoms  seems  to  have  some 
relation  to  the  physical  characters  of  the  putrilage :  thus,  the 
more  fluid  the  products,  the  more  readily  the  constitutional 
symptoms  seem  to  be  produced — the  more  coherent,  the  drier 
the  products,  the  more  do  the  effects  aj)pear  in  local  processes; 
at  least  such  are  the  impressions  I  have  received  from  the  ob- 
servations so  far  made. 

In  regard  to  the  directly  appreciable  effects  of  the  gangrenous 
putrilage  of  hospital  gangrene,  the  following  observations 
have  been  made :  The  first  effect  is  the  coagulation  of  blood 
in  the  blood  vessels  on  or  near  the  surface  to  which  it  is  ap- 
plied. This  coagulating  power  manifests  itself  sometimes  in 
the  blood  of  large  and  thin-walled  veins,  seldom  in  the  large 
arterial  branches.  A  few  instances  have  occurred  in  which 
the  saphena,  or  its  branches,  have  been  involved  in  the  pro- 
gress of  the  gangrenous  chasms.  In  such  instances  it  was 
noticed  that  the  vein,  if  destroyed  at  all,  was  destroyed  very 
slowly,  but  that  the  first  change  was  the  coagulation  of  the 
blood  in  the  vein.  In  a  few  cases  the  vein,  though  exposed 
and  bared  of  its  sheath,  was  not  destroyed.     In  such  cases  the 


nOSPITAL   GANGRENE,   ERYSIPELAS,    AC.  19 

vein  was  almost  uniformly  felt  to  be  hard,  whip-cord-like, 
the  induration  beginning  at  the  distal  margin  of  the  excava- 
tion and  extending  a  little  beyond  the  cardiac  margin.  The 
hemorrhages  which  have  occurred  have  all  been  arterial.  This 
coagulating  power  of  the  putrilage  seem?  most  marked  in  the 
thin-walled,  deep-seated  veins — least  marked  in  the  thick- wall- 
ed, muscular,  superficial  veins.  In  the  smaller  veins  tlio  co- 
agulation is  complete.  In  the  larger  veins  the  coagulation 
takes  on  more  the  chai^acter  of  growing  thrombus.  JSTow  it  is 
a  noticeable  and  pregnant  fiict,  that  the  thrombi  which  were 
found  to  be  formed  in  the  larger  veins  seemed  to  have  their 
commencement  at  that  point  where  the  gangrenous  cavities 
came  nearest  in  contact  with  the  vein,  and  the  thrombus 
seemed  to  start  a  little  heartwards  from  that  point,  extending 
thence  toward  the  heart.  The  observatibns  on  this  point  have 
not  been  numerous  enough  to  warrant  the  promulgation  of 
this  statement  in  the  form  of  a  universal  truth,  but  they  tend 
in  that  direction. 

The  fluid  parts  of  the  putrilage  seem  to  flow  into  the  cellu- 
lar planes,  inducing  in  them  a  sort  of  gangrenous  liquefaction. 
The  tendency  of  hospital  gangrene  to  spread  through  cellular 
planes  seems  to  be  explained  by  this  fact.  In  some  of  the 
cases,  where  the  disease  had  manifested  itself  on  a  large  sur- 
face, spreading  with  frightful  rapidity — cases  in  which,  on  the 
application  of  our  remedies,  the  disease  was  promptly  ar- 
rested— the  muscles  could  be  seen  as  nicely  dissected  as  if 
prepared  for  class  demonstration  by  the  anatomist's  knife. 

Occasionally  a  condition  of  things  is  developed  in  the  sub- 
cutaneous cellular  planes,  throughout  great  districts,  in  which 
the  cellular  substance  is  seen  to  grow  yellowish,  lose  its  cohe- 
rence, and,  in  the  more  advanced  stages,  break  down  into  a 
putrid,  yellowish  fluid.  This  fluid,  under  the  microscope,  is 
seen  to  consist  of  fine,  granular  matter,  is  totally  devoid  of 
cells,  and  presents  threads  of  inelastic  fibrous  tissue.  This  dif- 
fluence  of  the  cellular  tissue  eventually  becomes  completed  to 
such  an  extent  that  the  fluid  products  flow  from  part  to  part, 
leaving  the  superior  portion  with  the  skin  (of  an  arm,  for  exam- 


20  A   REPOKT   ON 

pie)  appearing  like  a  flaccid  bag.  The  sldu  becomes  discolored, 
but  is  not  tliickened  and  indurated  as  in  facial  erysipelas.  In 
some  cases  the  skin  ig  pale,  sometimes  livid ;  at  certain  points, 
and  generally  to  a  large  extent,  the  skin  becomes  necrotic.  The 
disease  spreads  in  all  directions,  but  chiefly  downward.  In 
those  who  live  long,  small  flocculent  sloughs  pass  away,  but  the 
bulk  of  the  discharges  is  the  thin,  yellowish,  stinking  fluid 
above  described. 

The  predominating  symptoms  are  chills,  small  and  frequent 
pulse,  dry  hot  skin,  dark  yellowish  tint,  red  and  dry  tongue, 
distressing  hacking  cough,  frequent  and  superficial  respiration, 
singultus,  hebetude,  sopor,  and  delirium.  This  answers  to  the 
so-called  phlegmonous  erysipelas,  and  differs  from  the  limited 
abscesses  so  common  in  the  eyelids  in  facial  erysipelas.  Be- 
sides the  influence  exerted  by  the  putrilage  upon  the  blood 
contained  in  the  vessels,  it  starts,  in  the  tissues  with  which  it 
comes  in  contact,  the  putrefactive  process.  No  transitional 
state  of  the  tissues  touched  has  as  yet  been  observed.  The 
gangrenous  and  living  parts  are  shaded — blended  into  each 
other— so  blended  that  it  is  not  possible  with  the  naked  eye  to 
see  where  the  dead  tissue  ends  and  where  the  living  begins. 
The  tissues  soon  deliquesce,  but  this  deliquescence  is  not  pro- 
gressive ;  the  older  parts  of  the  sloughs  do  not  appear  to  be 
materially  softer  than  the  newly  forming  sloughs.  Some  of 
the  elements  of  the  tissues  seem  almost  always  to  aflbrd  a 
dirty,  yellowish  fluid,  a  fluid  which  can  be  readily  expressed 
from  the  coherent  parts  of  the  slough. 

This  fluid  contains  no  corpuscular  bodies,  is  not  separable 
into  a  supernatant  serum  and  sediment  by  standing ;  it  has  no 
quality  of  pus,  except  its  fluidity  and  color.  Pus  corpuscles 
have  never  been  seen  in  the  products  of  a  gangrenous  sore,  un- 
less at  some  point  granulation  was  going  on.  From  all  that 
can  be  seen,  the  parts  die — are  destroyed  in  pretty  much  the 
same  manner  as  they  are  destroyed  by  continuous  rubbings 
of  a  tumor  with  caustic  potash. 

It  will  be  seen  that,  in  my  opinion,  at  least,  these  three  aflcc- 
tions,  hospital  gangrene,  pyaemia,  and  erysipelas,  are  in  some 


HOSPITAL   GANGRENE,   ERYSIPELAS,   iC.  21 

way  connected  witli  miasms,  or  with  poisonous  substances,  by 
some  process  developed  in  animal  matter  in  the  course  of  a  se- 
ries of  chemical  actions  expressed  in  the  generic  term,  putrefac- 
tion. In  consonance  with  these  views,  and,  indeed,  under  the 
domination  of  this  idea,  the  search  was  instituted,  having  for 
its  object  the  discovery  of  an  agent  possessed  of  the  power  of 
arresting  putrefaction  and  of  destroying  the  products  of  putre- 
faction in  whatever  form  those  products  might  present  them- 
selves, solid,  fluid,  or  gaseous.  Just  at  this  point  I  had  to 
deal  with  the  difficulty  which  presented  itself  in  the  poverty 
of  our  knowledge  of  these  putrefactive  processes,  their  pro- 
ducts and  Effects  upon  the  living  organism. 

In  order  to  be  able  to  state  the  exact  extent  of  our  knowledge 
of  this  matter  in  its  chemical  aspect,  I  here  insert  a  note  from 
Acting  Assistant  Surgeon  Jenkins,  an  expert  chemist,  charged 
with  the  investigation  of  the  diseases  in  question,  so  far  as 
appertains  to  the  application  of  practical  chemistry. 

"  Louisville,  Ky.,  April  2d,  1863. 
"Dr.  M.  Goldsmith: 

"  Bear  Sir — In  reply  to  your  inquiry  of  a  few  days  ago,  ask- 
ing me  to  state  what  is  known  at  the  present  time  as  to  the 
chemical  nature  of  the  causes  producing  or  the  products  re- 
sulting from  infectious  diseases,  gangrenous  ulcers, .  etc.,  I 
thinkl  can  safely  say  that  little  or  nothing  is  known  as  to  the 
real  and  substantial  causes  of  such  morbid  processes  ;  and  in 
reference  to  the  nature  of  the  products  emanating  from  ulcers, 
etc.,  about  all  we  know  is  this:  the  effluvia  from  foul  and 
putrescent  ulcers  are  composed  chiefly  of  sulphuretted  and 
phosphuretted  hydrogen,  ammoniacal  and  sulphuretted  am- 
moniacal  gases,  "with  a  little  earburetted  hydrogen.  All  of 
these  bodies  have  been  proved  to  be  incompetent  to  induce 
diseases  similar  to  those  which  gave  rise  to  them. 

"  Among  the  many  substances  which  have  been  employed 
with  a  view  to  the  arrest  of  the  disease,  or  the  checking  or 
prevention  of  putrefaction,  or  the  destruction  of  the  noxious 
vapors  and  gases,  maybe  enumerated  both  physical  and  chem- 
ical agents,  such  as  charcoal  to  absorb,  balsamic  fumigations 
to  disguise,  and  antiseptics  to  change  the  chemical  compo- 
sition of  the  volatile  products  of  putrefaction — for  example, 
chlorine,  some  oxy-acids  (hyponitric  acid,  sulphurous  acid). 


22  A   REPORT    ON 

Some  salts,  (nit.  of  lead,  sulphate  of  iron,)  again  act  by  a  thor- 
oughl}^  destructive  effect  upon  the  substance  of  the  affected 
tissues,  anddestro}'  the  integrity  of  the  organized  structure,  e.g.^ 
corrosive  acids,  caustic  alkalies.  Others,  again,  act  in  a  milder 
manner,  and  appear  only  to  coagulate  the  albuminous  fluid  in 
and  about  the  diseased  parts,  e.  g.,  corrosive  sublimate,  nitrate 
of  silver,  etc.  As  an  example  of  what  we  know  in  reference 
to  the  action  of  antiseptics,  such  as  chlorine,  nitrous  acid,  sul- 
phurous acid,  etc.,  I  will  state  that  they  decompose  the  organic 
body  giving  rise  to  offensive  and  noxious  emanations,  and  act 
as  disinfectants  and  antiseptics, 

"1st.     By  abstracting  water. 

"2d.  By  forming  with  organic  matters  compounds  less  sus- 
ceptible of  decay.  * 

"  3d.     By  deodorizing  the  body. 

"  4th.  By  destroying  cryptogamic  plants  and  infusorial  ani- 
malcules. 

"Little,  also,  is  known  upon  this  subject,  of  a  definite  nature, 
as  most  of  the  experiments  have  been  made  with  a  view  not 
to  strike  at  the  cause,  but  to  destroy  the  noxious  character  of 
the  products  of  putrid  disease. 

"  Very  respectfully  yours,  &c., 

(Signed,)  "  THOS.  E.  JEKHIXS." 

In  looking  over  the  lists  of  the  agents  already  in  use  in  gan- 
grenous aftections  it  was  found  that  the  corrosive  acids  and  the 
actual  cautery,  the  most  potent  to  arrest  the  gangrene,  involved 
the  large  destruction  of  living  tissues,  and  therefore  were  not 
apphcable  to  the  arrest  of  the  process,  except  upon  open  sur- 
faces. Their  operation  is  limited  to  the  mere  charring  of  the 
tissues.  Neither  could  be  brought  safely  into  gangrenous 
caverns,  and  both,  in  their  clinical  application,  ai-e  attended 
with  so  many  disadvantages  that  they  have  not  completely 
answered  the  purposes  in  view.  As  to  the  other  agents  in 
vogue,  although  operating  in  the  right  direction,  they  are  in- 
effectual, confessedly  so — a  fact  most  eloquently  attested  in 
the  death-rate  whicli  attends  upon  the  disease. 

My  attention  was  at  once  turned  to  the  lialogens,  and  to 
substances  acting  like  the  halogens.  The  halogens,  as  is  well 
known,  are  fluorine,  chlorine,  iodine,  and  bromine.  The  ac- 
tion of  these  substances  is  alike  in  kind,  but  diirercnt  in  de- 


HOSPITAL    GANGRENE,    ERYSIPELAS,    &C.  23 

gree.  They  difFer  in  their  physical  properties.  Fhiorine  can- 
not be  isolated  on  account  of  its  ravenous  activity.  Chlorine 
cannot  be  had  pure  except  as  a  gas,  or  as  a  fluid,  unless  under 
pressure,  and  all  the  solutions  of  chlorine  are  feeble  in  their 
action.  Iodine  cannot  bo  had  at  ordinary  temperatures  in  a 
gaseous  state,  and  cannot  be  employed  except  in  a  solid  state, 
or,  if  in  a  fluid  state,  too  largely  diluted  to  possess  the  neces- 
sary degree  of  activity. 

Bromine  was  found  to  be  a  fluid  vaporable  at  ordinary  tem- 
peratures, and,  unlike  chlorine,  respirable  without  injury  or  in- 
convenience. 

Dr.  Brainard,  of  Chicago,  had,  as  I  am  informed,  already 
found  in  his  researches  upon  the  bite  of  the  rattlesnake,  that 
iodine  mixed  with  the  virus  destroyed  its  activity,  and  had 
shown  that  like  effects  were  produced  upon  other  animal  poi- 
sons. From  these  facts,  bromine  seemed  to  hold  out  the  most 
promise  for  the  purposes  in  view.  Reasoning  from  the  active 
antagonism  known  to  exist  between  the  halogens  and  animal 
poisons  in  substance,  the  inference  seemed  reasonable  that  a 
gaseous  halogen  would  be  antagonistic  to  vaporous  animal 
poisons.  Indeed,  this  quality  had  already  been  proven  to 
exist  in  chlorine.  The  objection  to  chlorine  for  the  pur- 
poses of  disinfection,  in  wards  occupied  by  the  sick  or  well,  is 
that  very  small  quantities  of  it  render  the  atmosphere  irrespira- 
ble;  and,  as  the  amount  requisite  was  found  to  be  larger  than 
was  compatible  with  respiration,  no  trials  were  made  of  it. 

The  first  occasions  for  the  experimental  use  of  the  agent 
selected  were  in  connection  with  erysipelas,  its  prophylaxis 
and  treatment.  Finding,  as  will  be  seen  by  the  records  ap- 
pended, that  the  indications  were  fulfilled  beyond  our  most 
sanguine  expectations,  the  bromine  was  supplied  in  large 
quantities,  and  held  ready  for  use  in  hospital  gangrene  should 
it  appear  in  our  hospitals.  The  records  in  regard  to  its  eftects 
in  this  disease  are  herewith  appended. 

Investigations  are  now  on  foot  in  regard  to  pyaemia,  and  the 
use  of  the   bromine  and   its  analogues  in  prevention.     The 


24  A    REPORT    ON 

cases  apt  to  be  observed  and  treated  with  tliis  agent  have  not 
been  sufficiently  numerous  to  develope  well-grounded  results. 
They  promise  still  more  important  results  than  have  been 
reached  in  the  treatment  of  erysipelas  and  hospital  gangrene — 
more  important  only,  however,  from  the  fact,  that  pycemia  is 
more  frequent  in  its  occurrence,  and  destroys  more  lives  than 
both  the  other  diseases. 

The  cases  of  hospital  gangrene,  which  have  been  treated  in 
the  hospitals  at  this  place,  have  presented  some  constancy  in 
most  of  their  characteristics  ;  and  in  order  that  the  true  nature 
of  the  disease  may  be  apparent  to  the  Surgeon  General,  I  will 
state  the  appearances  commonly  presented:  1st.  The  gan- 
grenous aifection  presented  a  tolerably  constant  tendency  to 
the  assumption  of  a  somewhat  circular  form.  This  tendency, 
however,  was  frequently  interrupted  by  the  varying  efi'ects  of 
the  special  remedy  used.  Thus,  when  the  skin  was  not  under- 
mined to  any  great  extent,  the  disease  was  commonly  arrested 
immediately,  and  the  ulcer  left  presented  the  usual  circular 
form  ;  but  when  the  skin  was  much  undermined,  or  under- 
mined to  unequal  extent,  at  different  points  in  the  circumfe- 
rence, the  disease  was  not  arrested  as  promptly  at  one  point  as 
at  another,  and  thus,  eventually,  the  circular  form  was  lost. 
Then,  again,  the  gangrenous  erosion  had  sometimes  an  irreg- 
ular elongate  form,  coinciding  with  the  original  shape  of  the 
wound.  Sometimes  the  gangrene  attacked  the  walls  of  a 
wound  passing  through  a  limb,  and  presented  itself  as  the 
sloughing  core  of  a  ball  wound,  the  pulps  protruding  from  the 
apertures  of  both  entrance  and  exit. 

2d.  The  spread  of  the  gangrene  seemed  pretty  generally  to 
'be  influenced  by  the  succulency  of  the  tissues.  Thus,  when 
it  commenced  on  the  surface  in  a  superficial  wound  or  ulcer, 
it  generally  spread  most  rapidly  in  the  skin  and  cellular  planes. 
The  disease  continuing,  the  muscular  substance  would  next  be 
attacked.  Dense  fasciae,  as  the  fascia  lata,  and  tendons,  resist- 
ed the  influence  much  longer;  on  the  whole,  the  bones  suf- 
fered more  than  tendons.  Another  reason  why  the  disease 
spread  laterally  rather  than  deeply,  and  of  consequence  more 


HOSPITAL    GANGREI^E,    ERYSIPELAS,    &C.  I^D 

in  cellular  planes,  and  less  rapidly  towards  the  deeper  tissues, 
is,  that  the  sloughs  could  be  more  readily  detached  from  the 
exposed  parts  of  the  gangrenous  surface  so  as  to  allow  the 
effectual  application  of  the  remedy,  while  it  was  difficult  to 
detach  the  sloughs  underlying  the  skin,  and,  of  course,  difficult 
to  mix  the  remedy  with  the  sloughs — the  sine  qua  non  of  its 
curative  agency.  These  causes  have  operated  so  decidedly  in 
modifying  the  form  and  appearances  of  the  granulating  sores 
left  on  the  subsidence  of  the  gangrene,  that  many  of  the 
numerous  surgeons  visiting  this  place,  to  see  for  themselves 
the  effects  of  the  treatment  instituted,  have  found  it  difficult 
to  realize  that  they  were  looking  upon  the  ravages  of  hospital 
gangrene,  unless  it  so  happened  that  I  could  show  them  some 
cases  in  which  the  disease  was  in  progress. 

3d.  The  sloughs  were  variant  in  their  consistence,  and 
this  variance  ran  from  tolerably  firm  escars  to  diffluent  pulps. 
The  consistence  of  the  sloughs  coincided  rather  with  the 
consistence  of  the  tissues  sloughing.  The  sloughs  of  skin 
were  soft,  swollen,  tolerably  coherent  masses.  The  sloughs 
of  cellular  tissue  were  soft,  flocculent,  yielding  more  abun- 
dantly a  dirty  yellowish  fluid.  The  sloughs  of  muscles  were 
firmer,  less  pulpy,  more  coherent.  In  some  of  the  cases,  and 
especially  in  those  in  which  the  process  was  slower,  skin,  cel- 
lular substance,  and  muscles,  seemed  to  melt  away  into  mere 
diffluent  matter,  the  product  of  the  destruction  of  each  of  the 
several  tissues  in  these  cases  being  nearly  alike. 

4th.  The  sloughs  were  commonly  of  a  dirty  greyish  hue, 
those  of  the  skin  being,  in  most  instances,  somewhat  darker 
than  those  of  the  cellular  substance.  The  variations  of  color 
appeared  to  be  influenced  more  by  the  quantities  of  altered 
blood  in  the  tissues  than  by  an}-  other  condition. 

5th.  In  all  of  the  cases  there  was  present  a  most  pungent 
and  intolerable  fetor.  In  some  instances  the  pungency  of  the 
gaseous  effluvia  was  so  great  as  to  produce  a  persistent  smart- 
ing in  the  eyes  and  the  nares  of  the  persons  engaged  in  dress- 
ing the  sores.  The  odor  would  often  fill  the  whole  ward. 
This  fetor,  in  greater  or  less  intensity,  was  the  almost  constant 


26  A  REPORT   ON 

atteiidaut  upon  the  gangrenous  process,  appearing  when  it 
began,  continuing  as  it  continued,  and  ending  when  it  ended. 
So  constant  was  this  coincidence,  that  those  who  treated  the 
cases  came  to  regard  the  disappearance  of  the  fetor  as  the  re- 
liable evidence  of  the  arrest  of  the  disease  ;  the  presence  of  it, 
as  the  signal  of  the  commencement  of  the  process.  This  odor 
was  peculiar ;  it  was  not  the  sickish  odor  which  is  often  per- 
ceived in  suppurating  or  ulcerating  wounds,  nor  the  odor  of 
common  gangrene,  or  of  common  putrefaction  of  dead  animal 
matter,  but  an  odor  peculiar,  recognizable  with  the  nose,  but 
not  admitting  of  description, 

6th.  An  examinatioi;!  of  the  sloughs  under  a  microscope 
shows  that  the  fluid  products  consist  chiefly  of  a  granular 
debris,  and  of  fibres  of  inelastic  fibrous  tissue ;  for  the  rest, 
morphological  forms  of  the  tissues  are  gradually  lost. 

7th.  In  the  cases  under  observation,  the  only  local  con- 
dition rendering  the  parts  liable  to  the  invasion  of  the  gan- 
grene was  solution  of  continuity.  It  will  be  seen  that  the 
disease  was  developed  in  sores,  small  and  nearly  healed,  as 
well  as  in  those  which  were  extensive  and  recent;  that  in  one 
case,  especially,  it  was  developed  at  the  site  of  a  purpuric 
extravasation,  and  that  in  another  it  invaded  a  point  almost 
completely  cicatrized.  It  invaded  wounds  recent,  wounds  gran- 
ulating, and  wounds  ulcerating.  In  some  few  of  the  cases  the 
disease  could  be  traced  to  no  contagion ;  in  others  it  was  dis- 
tinctly traceable  to  the  presence  of  the  disease  in  other  patients. 
That  the  disease,  when  developed,  w^as  contagious  is  shown  by 
the  occurrence  of  several  cases  in  the  beds  next  adjoining 
those  already  affected. 

8th.  The  constitutional  state  existing  at  the  time  of  the  in- 
vasion, and  prior  to  the  invasion,  did  not  seem  to  have  much 
influence  upon  the  liability  to  the  disease;  for  the  latter 
seemed  to  invade  the  strong  and  the  feeble,  the  young  and  the 
old,  the  sick  and  the  well,  with  equal  facility.  Nor,  on  the 
whole,  was  it  noticed  to  advance  any  more  rapidly  in  those  of 
depraved  health  than  in  those  of  sound  health.  The  condi- 
tion of  the  health  seemed  to  have  much  to  do  with  the  .rapid- 


HOSPITAL    GANGRENE,   ERYSIPELAS,    AC.  27 

ity  and  tlie  vigor  with  wliicli  granulation  was  set  np  after  the 
gangrene  was  arrested,  but  to  have  little  to  do  with  the  liabil- 
ity to  or  the  progress  of  the  disease. 

9th.  The  constitutional  disturbance  wedded  to  the  disease 
was  also  variant  in  degree.  The  quality  of  the  disturbance 
was  pretty  uniform.  The  more  noticeable  symptoms  were : 
frequency  of  the  pulse,  running,  in  some  cases  which  I  ob- 
served personally,  to  150  per  minute — the  pulse  was  also  feeble 
and  small ;  the  appetite  in  every  case  was  diminished ;  in  some, 
lost ;  as  a  general  thing,  the  patients  expressed  a  disgust  for 
meat.  There  was,  also,  some  disturbance  of  the  nervous  sys- 
tem, expressing  itself  most  frequently  in  dullness  and  despond- 
ency, hebetude,  and  inability  to  sleep  refreshingly. 

The  skin  was  almost  always  of  a  dirty  brownish,  yellowisli 
hue — a  sort  of  muddy  hue.  There  w^as,  also,  in  all  of  the 
cases,  more  or  less  muscular  prostration.  In  some  of  the  worst 
cases,  especially  in  those  where  the  skin  was  much  under- 
mined, there  w^ere  colliquative  sweats,  chills,  and  saccharine 
odor  of  the  breath.  There  seemed  to  be  no  tendency  to 
diarrhea,  i^o  abnormities  in  the  appearance  of  the  teeth  and 
tongue  were  observable  except  in  one  or  two  instances.  The 
constitutional  symptoms  did  not  seem  to  have  any  marked 
relation  to  pre-existing  constitutional  states,  either  in  kind  or 
in  violence.  Some. of  the  mildest  of  the  constitutional  dis- 
turbances, the  extent  of  the  gangrenous  surfaces  being  kept  in 
view,  were  observed  in  those  emaciated  by  previous  disease. 

10th.  The  condition  of  the  surrounding  tissues  seemed  to 
have  little  or  no  influence  upon  the  progress  of  the  disease,  ex- 
cept in  this,  perhaps,  that  the  disease  advanced  rather  more 
slowly  but  more  persistently  through  those  parts  soliditied  by 
previous  inflammation.  There  was  generally  to  be  seen  a  lit- 
tle tumefaction  of  the  skin  alojig  the  line  of  the  advancing 
gangrene,  especially  where  there  was  much  fatty  substance  un- 
derlying the  skin.  This  tumefied  skin  was  often  somewhat 
red,  a  darkish  red ;  in  a  few  instances,  almost  livid.  This  line 
would  vary  from  the  smallest  appreciable  width  to  half  an  inch. 
In  other  instances  there  was  no  swelling  or  discoloration  of  the 


28  A   REPORT   ON 

siuTouncliug  edges.     The  advance  of  tlie  disease  evidently  had 
no  connection  with  any  inflammatory  process. 

11th.  The  surface  of  the  gangrenous  parts  was  generally  in- 
sensible. Bromine,  iodine,  and  creosote,  produced  no  pain, 
unless  they  reached  the  living  parts  below ;  nor  could  the  gan- 
grenous surfaces  be  said  to  be,  in  any  sense,  sensitive  or  irrita- 
iDle. 

In  some  cases  the  patient  complained  of  a  biting,  gnawing, 
stinging  pain — a  pain  always  relieved  by  the  efficient  applica- 
tion of  bromine.  In  some  few  cases  opium  was  needed  to 
procure  sleep  and  relieve  pain. 

12th.  Constitutional  remedies  seemed  to  have  no  decided  in- 
fluence over  the  disease,  or  over  its  local  or  general  expression, 
and  had  no  other  perceptible  influence  than  to  sustain  the 
strength  and  relieve  pain. 

13th.  The  disease  could  in  no  case  be  said  to  have  a  consti- 
tutional origin.  In  no  case  did  the  constitutional  symptoms 
precede  the  local  disease,  or  continue  after  the  gangrene  was 
arrested.  It  was  a  noticeable  feature  in  every  case,  that  the 
constitutional  symptoms,  whatever  their  character,  as  soon  as 
the  gangrene  was  arrested,  passed  away  immediately,  and 
as  rapidly  as  the  effect  of  alcoholic  intoxication  passes  off. 
In  some  of  the  cases  there  were  other  wounds  in  the  same  in- 
dividual :  thus,  one  man  had  a  musket  ball  to  pass  through  the 
fleshy  part  of  both  thighs ;  in  one  thigh  the  wound  became 
gangrenous,  and  in  the  other  kept  on  granulating  uninterrupt- 
edl}'.  In  this  man's  case  there  was  no  possibility  for  the  pro- 
duction of  the  disease  by  contagion — it  was  idiopathic.  Before 
the  occurrence  of  any  cases  in  our  hospitals,  I  had  directed  the 
surgeons  in  charge  to  procure  bromine,  so  as  to  have  it  ready 
for  use  in  case  the  disease  appeared.  Many  of  the  surgeons 
had  no  experience  in  the  use  of  the  remedy.  They  were  im- 
bued with  the  idea,  prevalent  in  the  profession,  that  this  agent 
is  a  highly  corrosive  and  irritating  one;  and,  hence,  they  al- 
most uniformly  used  it,  in  the  beginning,  largely  diluted  Avith 
alcohol,  water,  or  ether.  The  inefficiency  of  this  use  of  the 
remedy,  comparably  with  stronger  solutions,  or  with  the  bro- 


nOSPITAL   GANGRENE,   ERYSIPELAS,   &C.  29 

mine  in  substance,  will  1)C  seen  in  the  history  of  the  cases  ap- 
pended. As  the  surgeons  gained  experience  with  the  remedy, 
they  gained  confidence  in  its  efficacy,  and  learned  that  it  w^as 
not  the  corrosive  and  irritating  agent  which  they  had  supposed 
it  to  be.  Certain  clinical  difficulties,  however,  presented  them- 
selves, some  of  which  have  already  been  overcome  by  further 
trial,  some  have  not  yet  been  overcome. 

It  was  found  that  bromine,  pure  or  in  concentrated  solution, 
amongst  its  other  effects,  coagulated  the  albumen  of  the  sloughs, 
thus  encrusting  the  superficial  parts  so  closely  as  to  prevent 
the  bromine  flowing  into  or  reaching  the  deeper  parts.  The 
difficulty  was  overcome,  measurably,  by  first  removing  the 
sloughs  with  forceps  and  scissors,  so  that  but  a  thin  layer  of 
slough  covered  the  living  parts.  However,  it  was  not  found 
practicable  to  remove  the  undermining  sloughs  so  cleanly.  In 
these  cases  all  that  can  be  done,  as  yet,  consists  in  pushing 
the  bromine,  on  pointed  sticks  of  wood,  deep  into  the  slough- 
ing cellular  planes,  or  else  inserting  it  by  means  of  the  hypoder- 
mic syringe  through  the  sound  skin  into  and  in  advance  of 
the  advancing  sloughs,  or  injecting  it  into  cellular  planes  and 
gangrenous  cavities  by  means  of  gutta-percha  syringes.  What 
is  required  in  the  application  of  the  remedy  to  arrest  hospital 
gangrene  is  to  mix  the  bromine  thoroughly  with  the  slough,  and 
touch  everywhere  the  living  surface  of  the  sore.     This  is  all. 

Later  experience  with  the  bromine  in  my  own  hands  satis- 
fies me  that  the  following  directions  for  its  application  are  suf- 
ficient for  almost  any  contingency  : 

1st.  Frejparation.  If  the  gangrenous  sore  is  large,  or  the  pa- 
tient intolerant  of  pain,  chloroform  or  ether  should  be  admin- 
istered. 

2d.  The  surgeon  should  be  provided  with  basins,  sponges, 
dry  lint,  blotting  paper  if  at  hand,  a  stout  rubber  or  a  glass 
urethral  syringe,  a  small  measuring  glass,  some  ])ure  bromine, 
a  pair  of  forceps,  probe  scissors,  and  a  spatula,  or  the  handle 
of  a  scalpel. 

3d.  The  patient  being  prepared,  the  surgeon  should,  with  for- 
ceps and  scissors,  remove  all  the  sloughs  so  far  that  some  bleed- 


30  A   REPORT   ON 

ing  points  are  exposed.  The  bleeding  having  ceased,  or  been 
arrested  by  the  touch  of  the  bronciine,  he  next  scrapes  away 
the  fluid  putrilage  or  purulent  fluid  bathing  the  surface  of  the 
sore ;  he  now  turns  up  the  edges  of  the  skin,  and,  with  the 
handle  of  the  scalpel,  removes  all  the  pultaceous  matter  un- 
derlying the  skin.  The  flocculent  pulps  adherent  to  the  sur- 
faces underneath  are  now  removed  with  the  scissors  and  for- 
ceps. The  same  proceedings  are  practised  in  the  celhilar 
planes  between  muscles.  The  surfaces  are  now  to  be  dried, 
first  with  lint  or  tow,  and  finally  with  blotting  paper,  or  any 
dried  paper  pulp.  The  bromine  is  now  poured  into  the  glass 
measure  partly  filled  with  water.  The  syringe,  or  a  pipette,  is 
next  thrust  through  the  water  into  the  layer  of  bromine,  and  this 
is  drawn  up  into  the  syringe  or  pipette  ;  with  this  instrument 
the  bromine  is  applied,  first  to  the  cavities  between  the  mus- 
cles, next  under  the  skin,  next  to  the  exposed  surfaces  of  the 
sore. 

This  application  of  the  bromine  coagulates  and  hardens  the 
soft  flocculent  pulp,  and  gives  the  fluid  parts  of  the  putrilage 
the  consistence  of  brain  substance.  The  scissors  and  scalpel 
are  again  put  into  requisition  ;  the  gangrenous  portions  may 
now  be  easily  removed,  and  when  it  is  done,  from  under  the 
skin,  from  the  intermuscular  spaces,  and  from  the  exposed  sur- 
faces of  the  sore,  the  bromine  should  be  re-applied.  Where 
the  gangrene  attacks  the  elongated  track  of  a  ball-wound— 
traversing  a  limb,  for  example — a  piece  of  candle-wick,  thread- 
ed in  an  eyed  probe,  should  be  saturated  with  the  bromine 
and  passed  through  the  wound. 

Less  than  this  will  do  for  many,  for  most  cases ;  but  this  is 
the  eftectual  method.  The  beginner  with  this  practice  is  ad- 
vised to  adopt  it  closely  in  his  first  cases,  and  as  he  grows  fii- 
miliar  with  the  use  of  the  bromine  he  can  temper  the  agent 
to  the  necessities  of  the  particular  case.  Another  difficulty 
was  occasionally  noticed :  the  bromine  was  sometimes  applied 
too  often,  and  thus  the  separation  of  the  sloughs  and  the  oc- 
currence of  granulation  were  retarded.  Bromine  is  slightly 
corrosive,  that  is,  applied  to  a  granulating  surface,  it  coagu- 


HOSPITAL   GANGRENE,    ERYSIPELAS,   AC.  31 

lates  the  albumen  in  the  granulations  and  thus  kills  them  ; 
and,  to  the  eye,  there  is  but  little  difference  between  a  granu- 
lating surface  which  has  just  been  touched  with  bromine,  and 
a  gangrenous  surface  just  touched  with  it.  The  rule  for  its 
application  is  this :  First,  mix  the  bromine  with  the  slough, 
in  all  its  parts ;  then  allow  the  slough  to  come  off.  There  is 
no  necessity  for  a  second  application  unless  by  a  return  of  the 
fetor  it  is  evident  that  some  part  of  the  gangrenous  cavity 
has  not  been  reached  on  the  first  application. 

The  bromine  is  sometimes  applied  too  often,  sometimes  not 
often  enough ;  sometimes  the  solution  is  too  weak,  never  too 
strong;  sometimes  not  applied  thoroughly  §nough,  never  too 
thoroughly.  When  the  bromine  touches  sound  or  living 
abraded  skin  it  gives  rise  to  pain.  The  pain  is  sometimes 
slight,  sometimes  severe.  In  a  few  cases  we  have  had  to  ad- 
minister chloroform  in  order  to  secure  the. leisurely  and  thor- 
ough application  of  the  remedy.  The  pain  commonly  lasts 
for  a  few  minutes,  sometimes  for  an  hour.  The  immediate 
and  obvious  effects  of  the  application  of  the  bromine  to  a 
gangrenous  surface  are,  the  coagulation  of  the  albumen  and 
the  hardening  of  the  slough.  The  surface  becomes  in  some 
parts  a  whitish  yellow  in  color.  The  fetor  is  immediate!)/  arrest- 
ed. If  any  fetor  is  present  after  the  lapse  of  ten  minutes,  or 
after  the  odor  of  the  bromine  has  passed  off,  the  better  way  is 
to  remove  the  sloughs  still  further  from  under  the  edges  of 
the  skin  and  apply  the  bromine;  for,  just  so  surely  as  any 
fetor  remains,  there  is  some  portion  of  the  slough  with  which 
the  bromine  has  not  yet  been  mixed,  and  just  so  surely  the 
disease  will  not  be  arrested  in  all  parts  of  the  gangrenous  sur- 
face. As  to  subsequent  dressings,  our  convictions  are  not  yet 
settled:  some  use  dry  lint;  some,  yeast  poultices;  some,  warm 
water  dressings;  some,  lint,  wetted  in  a  weak  solution  of 
bromine. 

Another  important  point  to  which  attention  is  invited  is 
this :  No  cases  treated  in  these  hospitals  are  isolated ;  they  are 
treated  in  the  midst  of  other  wounded  men.    '"Wlien  the  bro- 


32  A   REPORT   ON 

mine  is  promptly  and  tliorouglily  applied,  the  disease  docs  not 
spread. 

In  the  beginning,  and  before  the  bromine  was  used  prompt- 
ly and  efficiently,  a  few  cases  were  produced  by  contagion, 
but  not  one  after  we  got  into  the  habit  of  using  the  remedy  in 
the  way  we  have  now  settled  upon.  In  one  of  the  hospitals 
two  cases  were  brought  into  the  house  with  the  disease  full- 
Hedged.  A  man  in  the  next  adjoining  bed  took  it;  another 
directly  across  the  ward  took  it ;  another  at  the  opposite  end 
of  the  ward  took  it ;  the  weather  was  cold,  the  ward  was  small 
and  ill-ventilated,  and  all  the  inmates  were  wounded  men. 
After  the  bromine  was  used,  no  new  cases  occurred. 

So  strongly  are  our  surgeons  impressed  with  this  applica- 
tion of  bromine,  that  they  have  lost  all  dread  of  hospital  gan- 
grene's spreading  in  their  wards.  We  have  still,  every  now 
and  then,  some  new  cases,  but  the  most  of  them  are  imported. 
"We  are  continually  receiving  wounded  men  from  the  front ; 
they  are  brought  here  in  crowded  boats  and  cars,  and  often 
their  wounds  are  not  dressed  from  the  time  of  departure  to 
the  time  of  arrival.  Most  of  the  cases  are  doubtless  developed 
in  transitu.^ 

In  the  ulcerous  and  gangrenous  affections  of  the  throat  oc- 
curring during  the  progress  of  scarlatina,  something  of  the 
same  effects  seem  to  be  be  produced  by  the  swallowing  of  the 
putrid  products  of  the  local  disease  as  are  noticed  in  those 
having  gun  shot  wounds  of  the  jaw  and  tongue.     Doubtless 

*  While  this  report  is  going  through  the  press  a  number  of  wounded  men  have 
arrived  from  the  battle-field  in  front  of  Chattanooga.  Some  thirty  \rere  admitted 
into  Hospital  No.  3,  in  this  city.  In  all  of  these  men  the  wounds  had  acquired  a 
gangrenous  character.  In  some,  this  character  was  fully  developed.  They  state 
that  their  wounds  have  not  been  dressed  since  they  left  the  field,  now  a  week  ago. 
Like  events  were  observed  in  some  of  the  wounded  sent  from  Philadelphia  to  Cin- 
cinnati. Their  wounds  were  not  dressed,  as  I  am  informed,  during  their  transit 
from  the  one  place  to  the  other.  In  both  series  of  cases  the  wounds  were  doubtless 
in  good  condition  before  the  men  started  on  their  journey.  The  occurrence  of 
gangrene,  in  so  many  instances  of  a  like  kind,  forces  upon  me  the  conviction  that 
the  gangrenous  quality  is  produced  in  these  cases  by  the  mere  confinement  and 
putrefaction  of  the  discharges  of  the  wounds;  for  it  was  noticeable  that  the  men 
were,  in  other  respects,  in  good  condition. 


HOSPITAL    GANGRENE,   ERYSIPELAS,    AC.  33 

tlie  piitrilagc,  in  tlie  former  cases,  exercises  the  usual  reaction 
upon  the  system  atharge,  noticeable  in  other  gangrenous  afi'ec- 
tions  in  various  parts  of  the  body. 

The  same  indications  are  measurably  to  be  fnet  in  the 
former  as  in  the  latter.  The  vapor  of  bromine  has  been  ap- 
plied in  both  the  scarlatinous  and  diphtheritic  affections,  with 
what  efl'ect  will  appear  in  the  subjoined  report.  Besides  its  an- 
tiseptic property,  bromine  seems  to  have  the  power  of  render- 
ing the  diphtheritic  exudation  more  brittle,  so  that  the  latter 
is  more  easily  exfoliated,  detached,  and  expelled.  I  have  not 
observed  personally  any  of  the  cases  of  scarlatina,  and  there- 
fore confine  my  report  on  these  diseases  to  the  report  of  cases 
herewith  appended. 

The  report  of  Surgeon  G.  K.  Weeks,  U.  S.  V.,  is  appended. 


SURGEON  WEEKS  S  REPORT. 

"  Report  on  Ilosjnial  Gangrene,  as  observed  in  General  Hospitals  in 
Louisville,  Ky. 
"I  was  requested  by  Surgeon  M.  Goldsmith,  Superintendent 
of  Hospitals  in  this  city,  to  visit  personally  all  the  hospitals  in 
and  around  Louisville,  and  collect  from  the  records  and  At- 
tending Sursreons  all  the  facts  that  have  occurred  in  connec- 
tion  with  cases  of  hospital  gangrene  during  the  winter  and 
spring.  Having  complied  with  this  request,  I  beg  leave  to 
submit  the  following  statement:  I  find  that,  up- to  the  present 
time,  115  cases  have  been  treated ;  in  108  of  these  the  gan- 
grene has  been  arrested,  and  the  patients  are  either  now  well 
or  convalescent.  Of  the  whole  number  treated,  7  have  died. 
104  were  treated  with  bromine,  and  of  these  none  have  died 
from  gangrene  ;  of  this  number  80  were  treated  with  the  solu- 
tion of  bromine,  and  24  with  pure  bromine.  The  average 
time  of  arrest  of  the  disease  in  the  cases  treated  with  the  solu- 
tio.n  of  bromine  was  8  days  and  19  hours  ;  in  the  cases  treated 
by  bromine  undiluted,  the  average  time  of  arrest  was  2.12  ;  in 
those  not  treated  hy  bromine,  14.6.  Of  the  number  treated 
by  bromine,  three  have  died,'~two  from  pyaemia,  and  one  from 
3 


34  A   REPORT    ON 

cellulitis ;  in  all  of  these,  gangrene  had  been  previously  ar- 
rested, as  \Yill  be  observed  by  referring  to  the  accompanying 
report.  The  condition  in  each  case  was  verified  by  a  post- 
mortem examination.  In  the  two  individuals  who  died  of 
pytemia,  metastatic  abscesses  were  found  in  the  lungs,  and 
thrombi  in  the  veins.  I  have  thrown  out  case  No.  13,  for  the 
reason  that  I  am  satisfied  no  definite  plan  of  treatment  was 
followed.     The  facts  elicited  are  these :     The  man  was  brought 

fi^om to  Hospital  No.  3,  in  this  city ;  at  the  time  of 

his  admission,  his  system  was  much  reduced  by  abscesses  of  a 
.bad  nature,  in  the  region  of  the  thigh,  the  bone  of  which  was 
wounded  at  the  battle  of  Shiloh,  on  the  7th  of  April,  1862. 
The  wound  became  gangrenous  after  his  admission  to  Hospital 
No.  3.  The  surgeon  in  charge  stated  that  it  was  impossible 
to  apply  bromine  thoroughly,  on  account  of  immobility  of  the 
patient,  the  position  and  nature  of  the  wound ;  and  that,  in 
liis  opinion,  it  was  not  applied  to  all  the  diseased  surfaces. 
Gangrene  burrowed  into  the  cellular  spaces ;  the  patient  had 
to  be  raised  to  have  the  bromine  applied,  and  the  motion 
caused  so  much  pain  that  it  was  found  impracticable  to  apply 
the  remedy  to  any  useful  purpose.  I  should  state  also,  in  this 
connection,  that  the  patient  had  a  colliquative  diarrhea,  to 
which  the  attending  surgeon  attributed  his  death.  By  refer- 
ence  to  accompanying  report,  it  will  be  seen  that  eleven  cases 
have  been  treated  by  other  remedies  than  bromine.  Of  this 
inumber  three  died,  and  nine  recovered  :  of  the  latter,  one  was 
treated  with  creosote ;  two  by  extract  of  hrematoxylon ;  two 
by  chlor.  soda,  charcoal,  and  yeast;  one  by  mur.  tinct.  iron  ; 
■  one  by  nitric  acid  ;  and  one  by  warm  water  dressings. 

""Both  these  and  the  cases  treated  by  bromine  had  the  same 
constitutional  treatment,  namely:  stimulants,  tonics,  and 
nutritious  diet;  with  the  exception  of  those  treated  in  Hos- 
•pital  No.  8,  where  the  hyposulphite  of  soda  was  used  without 
any  apparent  benefit;  the  compound  sol.  of  bromine  was  also 
i(ivcn  internally,  and  the  surgeon  though^  with  a  good  efifect. 
The  liyposulphite  of  soda  was  given  in  10  gr.  doses,  three 


HOSPITAL    GANGRENE,    ERYSIPELAS,    iC.  3o 

times  a  clay,  and  the  solution  of  bromine  was  administered  in 
the  dose  of  three  drops  three  times  a  day.  * 

*'It  will  be  seen  from  the  foregoing  statements  that  no  deaths 
occurred  from  hospital  gangrene,  directly,  where  bromine  was 
used;  that  three  of  these  patients  died,  subsequently,  of  other 
affections;  also,  that  of  the  eleven  cases  otherwise  treated, 
three  died,  or  over  twenty-five  per  cent.  When  the  remedy 
was  first  introduced  at  this  post,  by  Surgeon  M.  Goldsmith,  it 
was  used  mainly  in  the  strength  of  bromine  1  part,  water  24. 
Under  this  treatment  it  will  be  observed,  that  the  average  date 
of  arrest  was  12.61  days ;  but  after  Smith's  formula  was  pre- 
scribed the  average  duration  was  8.19  ;  and  that  in  the  twenty- 
four  cases  treated  bj'pure  bromine,  (these  were  the  worst  cases,) 
the  average  was  2.12  days — showing,  conclusively,  that  the  pure 
bromine  arrested  it  in  the  shortest  period  of  time.  In  con- 
sidering the  several  interesting  facts  falling  under  my  observa- 
tion, the  following  seemed  peculiarly  note-w^ortliy : 

"  1st.     The  strength  of  the  article  used. 

"2d.     The  condition  of  the  parts  to  which  it  was  af)plic(l. 

"  3d.     The  manner  of  its  application. 

"The  solution  of  the  varying  eftccts  of  the  treatment  seems 
to  me  to  be  found  in  the  study  of  the  foregoing  points. 

"  I  found  a  common  error  in  the  cases  where  the  bromine  had 
appeared  to  act  inefficiently.  Sometimes  the  article  used  was 
not  of  sufficient  strength;  in  others,  the  wound  was  not  well 
prepared  to  receive  it ;  and  in  some,  it  was  applied  too  often, 
thus  preventing  the  natural  powers  from  establi.-hing  the  re- 
parative process  in  the  wound,  even  after  the  complete  destruc- 
tion of  the  materies  morhi  in  the  part.  From  all  the  facts 
observed,  I  believe  the  following  mode  of  application  generally 
to  be  the  best :  First,  the  sloughs  should  be  cleanly  dissected 
away  until  we  meet  evidences  of  vitality,  or  by  hemorrhage 
are  warned  to  go  no  further — being  careful  to  clean  out  all 
nooks  and  corners  where  the  gangrene  has  dipped  down  into 
intermuscular  spaces,  or  followed  along  cellular  planes,  where, 
unobserved,  it  makes  its  nidus  safe  from  observation,  too  surely 
to  resume  its  onward  progress  if  not  reached  by  the  remedy. 


36  A   REPORT    ON 

Second ;  After  haviDg  removed  all  tlie  dead  tissues,  tlie  wound 
should  be  washed  thoroughly  in  warm  water,  injecting  with  an 
ear  syringe  all  the  parts  otherwise  difficult  to  reach.  Then  the 
wound  should  be  eflectually  dried  with  a  pledget  of  lint  or 
charpie,  using  the  same  care  in  regard  to  small  cavities  extend- 
ing from  the  central  sore ;  for  the  reason  that  if  bromine  comes 
in  contact  with  the  albumen,  or  solution  of  albumen,  it  imme- 
diately coagulates  it,  and  thus  forms  a  barrier  to  the  further 
diffusion  of  the  remedy.  I  saw  many  evidences  of  the' viola- 
tion of  this  rule  whilst  visiting  the  hospitals.  The  surgeon 
would  frequently  remark :  '  The  gangrene  was  arrested  every- 
where, except  in  two  or  three  small  points  as  large  as  the  end 
of  the  finger ; '  and  these  were  always  found  to  be  rich  in  cellu- 
lar tissue,  occupying  intermuscular  spaces,  along  which  the 
process  had  traveled  with  more  rapidity  than  at  any  other,  and, 
consequently,  it  frequently  extended  beyond  the  reach  of  the 
remedy,  and  passed  beyond  the  limit  of  vision.  Third :  Having 
the  wound  thus  prepared,  pure  bromine  should  be  applied  with 
a  mop  or  swab  to  every  part  of  it.  If  all  the  surfaces  cannot 
be  reached  in  this  way,  the  bromine  should  be  injected  into 
the  smaller  cavities  with  a  glass  syringe,  (and  with  a  pointed 
stick  of  wood,  adapted  to  the  dimensions  of  the  cavity,  with 
the  end  covered  or  not,  as  the  case  may  require,  by  a  piece  of 
soft  cloth  or  lint.)  It  should  be  pressed  up  and  thoroughly 
mixed  with  all  the  pulp  or  pultaceous  fluid  that  may  still  linger 
in  the  wound.  Simi)le  dressings  should  then  be  applied,  and 
the  wound  excluded  from  the  atmosphere.  On  the  second  or 
third  day  after  the  application,  warm  water  dressings  should 
be  used  to  facilitate  the  detachment  of  the  sloughs,  and  to 
wash  away  all  molecular  matter  that  may  have  accumulated  in 
the  wound.  In  four  or  five  days  granulations  may  be  observed 
springing  up,  and,  if  no  fetor  be  present,  the  cure  will  be  com- 
plete. However,  if  some  fetor  still  lingers  about  the  wound,  it 
is  evident  that  some  points  have  escaped,  and  these  should  be 
re-touched,  observing  the  same  rules  as  in  the  first  application 
of  the  remedy,  and  being  careful  to  apply  it  only  to  the  places 
where  the  gangrene  is  not  arrested.     The  wound  should  then 


HOSPITAL   GANGRENE,   ERYSIPELAS,   &C.  37 

be  treated  on  general  principles.  The  only  case  where  I  would 
use  the  solution  of  bromine  is,  as  a  local  stimulant,  where  the 
granulations  are  weak.  I  believe,  where  pure  bromine  is  thus 
applied,  one  application  is  sufficient  to  arrest  the  disease.  As 
yet,  no  case  has  occurred  which  has  needed  a  second  applica- 
tion of  the  remedy  where  it  has  been  used  in  the  manner 
heretofore  stated;  and,  for  my  part,  I  cannot  imagine  tlie 
condition  that  would  demand  it.  In  regard  to  the  repetition 
of  the  application,  I  consider  it  of  as  much  importance  to 
a,wait,  after  one  efficient  application,  the  detachment  of  the 
sloughs  and  commencement  of  granulation,  as  I  do  the  ap- 
plication of  the  remedy  in  the  first  instance.  It  is  just  as 
impossible  for  repair  to  be  set  up  in  a  wound  where  bromine 
is  used  frequently,  as  if  nitric  acid  was  applied  in  its  stead. 
Although  the  process  is  stayed,  repair  is  prevented  by  the 
frequent  re-application  of  the  remedy.  This  fact  is  well  illus- 
trated in  Case  93,  where  pure  bromine  was  said  to  have  been 
applied  twice  a  day  for  a  month  before  granulations  made 
their  appearance,  and  the  surgeon  might  have  added  that  they 
would  have  never  been  observed  if  he  had  not  ceased  to  apply 
the  remedy;  for  then  granulations  made  their  appearance, 
which  would  have  been  also  the  case  if  he  had  ceased  the  ap- 
plication sooner.  This  is  the  explanation  of  all  the  cases 
reported  in  which  bromine  was  used  for  the  period  of  one  or 
two  weeks,  and  was  reported  to  have  failed  to  arrest  the  dis- 
ease. When  bromine  was  first  used  here,  it  was  commonly 
applied  in  a  weak  solution  three  times  a  day.  It  will  be.  seen 
that,  in  some  eases,  after  the  remedy  was  discontinued,  or  an- 
other of  a  more  harmless  character  substituted,  the  wound 
rapidly  granulated.  As  a  case  in  point  I  refer  to  Case  25, 
occurring  in  Hospital  No.  4.  •  In  this  case  the  disease  re- 
sisted the  action  of  the  compound  solution  of  bromine,  as  the 
surgeon  stated,  and  was  arrested  by  a  weak  solution  of 
creosote. 

"  It  will  be  seen  by  noticing  the  three  following  cases  (as  the 
surgeon  treated  them  all  in  the  same  manner)  that  he  was  of 
the  opinion  that  in  creosote  he  had  a  better  remedy  than  bro- 


38  A    REPORT    ON 

mine — a  proposition  lie  lias  failed  to  verify,  as  will  be  learned 
from  Case  30,  where  creosote  was  used  for  ten  days  with- 
out any  perceptible  arrest  of  the  process,  after  which  it  was 
arrested  by  three  applications  of  bromine.  This  case  I  saw. 
It  was  on  the  inner  aspect  of  the  left  thigh,  below  Scar- 
pa's triangle,  and  was  about  six  inches  in  diameter.  The  same 
length  of  the  internal  saphenous  vein,  running  directly  across 
the  sore,  was  destroyed.  This  wound  is  now  rapidly  filling  up 
with  granulations,  and  the  patient  doing  well  in  every  respect. 
In  the  investigations  of  these  cases,  many  interesting  facts 
were  observed  in  regard  to  the  effect  of  the  local  application 
of  bromine  to  gangrenous  sores  on  the  constitutional  symp-. 
toms,  the  entire  weight  of  evidence  being  that  the  constitu- 
tional disturbance  and  manifestations  began  to  disappear  as 
sooit-aS  the  local  disease  was  arrested  by  the  remedy.  This 
was  observed  by  friends  and  visitors,  as  well  as  physicians, 
namely :  The  rapidity  with  which  the  constitution  rebounded 
after  being  relieved  of  its  burden.  The  anxious  and  pinched 
expression  of  the  countenance,  the  general  feeling  of  lassi- 
tude, languor,  and  debility,  the  leaden  hue  of  the  surface, 
rapidly  passed  away ;  the  skin,  if  clammy  and  bathed  in  per- 
spiration, became  warm  and  dry ;  the  pulse  rose  in  strength, 
and  decreased  in  frequency;  the  appetite  returned;  and,  in 
short,  all  the  organs  began  to  assume  their  natuml  tone  and 
vigor.  These  effects  were  observed  very  constantly,  immedi- 
ately after  the  first  application  of  bromine,  and  could  not  be 
attributed  to  the  constitutional  treatment,  as  the  same  condi- 
tion was  observed  where  no  constitutional  treatment  had  been 
used.  I  leave  the  argument  for  others;  my  limits  will  only 
permit  the  simple  record  of  the  facts. 

"I  wish  also  to  direct  attention  to  another  yery  important 
point,  namely :  the  practicability,  by  the  aid  of  bromine,  of 
tying  an  artery  in  a  gangrenous  sore  where  secondary  hemor- 
rhage has  occurred. 

"  If  bromine  will  arrest  gangrene  as  certainly  and  as  speedily 
as  this  report  shows,  can  there  be  any  objection  to  tying  the  ar- 
tery in  the  wound?   thus  following  the  original  rule  of  Guth- 


HOSPITAL   GANGRENE,   ERYSIPELAS,   &C.    •  39 

rie,  directing  that  tlie  bleeding  vessel,  if  it  can  be  reached, 
shall  always  be  secured  in  the  wound.  If  we  tie  it  immedi- 
ately beyond  the  dead  and  in  the  living  tissue,  and  if  by  the 
aid  of  bromine  wc  are  certain  of  arresting  the  further  invasion 
of  the  parts  by  the  gangrenous  process,  what  objection  could 
be  urged  against  this  procedure  ?  It  is  in  cases  of  this  char- 
acter that  bromine  holds  superiority  over  nitric  acid  and  all 
other  known  remedies — the  capability  of  arresting  the  gan- 
grene without  destroying  important  parts  which  cannot  be 
avoided  in  the  application.  Case  No.  4  presented  itself,  and 
I  embraced  the  opportunity  of  ascertaining  the  facts  from  ac- 
tual observation. 

"  I  was  requested  to  see  this  man,  and  found  he  had  had  sec- 
ondary hemorrhage  to  the  extent  of  about  fifty  ounces.  I  found 
him  pulseless  and  cold  from  loss  of  blood.  His  leg  had  been 
amputated  January  1st,  18G3.  The  flaps  had  all  sloughed  off, 
the  tibia  projecting  two  inches.  I  directed  that  he  should 
have  stimulants,  and  waited  a  short  time  until  he  partially  ral- 
lied. I  then  prepared  the  wound  asJtieretofore  directed.  Upon 
loosening  the  tourniquet,  the  anterior  tibial  artery  bled  freely; 
I  tied  it  in  the  wound  just  below  the  junction  of  the  upper  and 
middle  third  of  the  tibia,  and  applied  pure  bromine  effectually 
to  the  wounded  surface.  I  kept  the  tourniquet  on  loosely,  and 
an  attendant,  instructed  in  its  use,  was  constantly  at  the  bed- 
side, day  and  night.  On  visiting  the  patient  next  day,  I  found 
him  very  comfortable;  pulse  100;  skin  warm;  appetite  bet- 
ter; looking  bright;  anguished  countenance  displaced  by  a 
more  cheerful  one.  There  was  no  fetor  emitted  from  the 
wound,  and  the  patient  was  every  way  doing  well ;  the  ligature 
came  away  on  the  fifth  day — no  hemorrhage  appeared;  he  is 
still  convalescing ;  wound  is  filling  up  slowly.  In  this  case 
granulations  were  slow  in  making  their  appearance — attribu- 
table to  the  great  loss  of  blood.  Applied  weak  solution  of 
bromine  to  the  wound;  the  case  is  now  convalescing  rapidly, 
and  no  hemorrhage  has  occurred.  Two  other  cases  illustra- 
ting the  same  principle,  to  some  extent,  have  occurred  in  hos- 
pitals in  this  city.     One  at  Hospital  'No.  3,  Case  G  of  accompa- 


40  ,  A   REPORT    ON 

nying  report,  where  the  brachial  artery  was  tied  in  a  gangre- 
nous sore  with  a  like  result.  Another  occurred  at  Hospital 
No.  12,  Case  Ko.  77*,  where  the  dorsalis  pedis  artery  was  tied 
under  the  same  circumstances  and  with  the  same  result. 

"  After  having  visited  all  the  hospitals,  gleaned  all  the  facts, 
lieard  all  the  evidence,  and  conversed  with  all  the  surgeons, 
the  impression  left  upon  my  mind  is,  that  in  bromine  we 
have  a  remedy  certain  in  its  eifects  for  the  arrest  of  hospital 
gangrene,  the  greatest  scourge  of  military  hospitals.  This  I 
am  aware  is  strong  language,  but  I  think  not  more  so  than  the 
circumstances  and  evidence  in  the  case  warrant.  I  expect 
most  confidently  the  future  will  verify  what  I  am  now  saying. 
Bromine  has  robbed  gangrene  of  its  terror,  and  shorn  it  of  its 
power  to  stalk  through  the  wards  where  the  sick  and  wounded 
are  congregated,  spreading  its  contagious  and  pestilential  influ- 
ence in  every  direction.  But,  armed  as  the  surgeon  now  is 
by  the  use  of  a  remedy  so  certain  in  its  effects,  a  feeling  of 
security  pervades  the  entire  profession  at  this  post,  not  only 
in  this,  but  in  all  that  family  of  diseases  formerly  supposed  to 
have  their  origin  in  blood  poisoning,  namely :  erysipekas,  gan- 
grenous diphtheria,  scarlatina,  &c. ;  its  use  allows  us  to  class 
hospital  gangrene  among  those  diseases  over  which  the  sur- 
geon has  as  absolute  and  complete  control  as  the  physician 
has  over  intermittent  fever.  I  am  forced  to  the  conclusion, 
from  all  the  facts  presented,  looking  at  them,  I  think,  with  an 
impartial  eye,  that  bromine  will  as  surely  arrest  hospital 
gangrene  as  quinia  will  ague. 

"GEO.  R.  WEEKS,  Surgeon  U.  S.  F." 


A  few  remarks  are  appended  which  force  themselves  so 
strongly  upon  my  attention  that  I  feel  I  must  give  them  utter- 
ance, however  heretical  and  revolutionary  they  seem  in  the 
presence  of  traditional  dogmata.  It  will  be  seen  that  in  the 
history  of  the  several  affections  treated  of  in  this  report,  one 
fact  seems  to  pervade  all  that  is  said,  and  that  is,  the  reac- 
tive influence  of  the  local  pathological  processes — the  constitu- 


HOSPITAL   GANGRENE,   ERYSIPELAS,   &C.  41 

tional  contaminations  caused  by  the  absorption  of  tbe  fluids 
produced  in  the  local  processes. 

That  constitutional  contaminations,  general  disease,  may  be 
produced  by  local  maladies,  is  shown  by  the  occurrences  ob- 
served in  syphilis,  in  vaccinia,  in  glanders,  in  rabies  canina, 
and,  from  what  is  recorded  in  the  cases  hereto  appended,  in 
hospital  gangrene.  In  these  diseases  it  is  evident  that  the 
abortion  of  the  local  processes  prevents  constitutional  con- 
tamination; or,  if  such  contamination  exists,  as  in  hospital 
gangrene,  the  symptoms  peculiar  to  the  general  malady  disap- 
pear quickly  after  the  arrest  of  the  local  process. 

Virchow,  I  think,  has  established  the  general  law  that  in  the 
sense  commonly  employed  there  is  no  such  thing  as  a  perma- 
nent dyscrasia.  He  has  shown  that  the  syphilitic  dyscrasia  is 
but  a  continuous  infection  arising  from  the  continued  produc- 
tion of  syphilitic  matter  in  the  lymphatic  glands  of  the 
neck; — that  with  the  subsidence  of  the  lymphatic  enlarge- 
ments, the  syphilitic  dyscrasia  disappears ; — that  the  can- 
cerous cachexia  is  but  a  continuous  infection  from  the  dif- 
fusion of  the  cancerous  juices.  The  vaccine  infection  dis- 
appears with  the  cicatrix  —  this  is  a  common  impression. 
"When  the  surgeon  examines  the  arm  of  a  person,  to  see 
if  re-vaccination  is  needed,  if  the  characteristic  scar  has  dis- 
appeared, he  re- vaccinates ;  if  he  finds  a  scar  good,  he  does 
not  re-vaccinate.  Besides,  there  is  good  reason  to  believe, 
though  the  cases  have  not  been  numerous  enough  to  warrant 
the  statement  as  a  settled  fact,  that  those  who  have  lost  the 
vaccinated  arm  by  amputation  at  the  shoulder  joint,  lose  their 
protection ;  so  that  we  are  at  least  w^arranted  in  entertaining 
the  suspicion  that  the  vaccine  dyscrasia,  so  to  speak,  is  a  con- 
tinuous infection  from  the  cicatrix. 

Further :  we  are  prepared  to  believe  that  thi's  is  true  of  the 
foregoing  diseases,  because  we  see  in  them  a  regular  series  of 
events  constantly  recurring  in  the  order  and  relation  of  cause  S 
and  effect.  If  we  could  see  a  certain  set  of  constitutional  dis- 
turbances, tolerably  constant  to  certain  local  processes,  (as,  for 
example,  the  symptomatic  fever  of  small-pox,  or  the  waxen 


42  A   REPORT   ON 

face  of  scarlatinous  fever  coincident  with  ulceration  of  the 
tonsils,)  disappear  whenever  the  Jocal  processes  were  arrested, 
surely  we  would  he  authorized,  whatever  our  idea  of  the 
original  disorder  may  have  been,  to  believe  that,  in  the  par- 
ticular states,  the  symptoms  referred  to  were  due  to  some  in- 
fluence exerted  by  the  local  processes  themselves. 

JSTow  what  are  the  facts  ? 

1st.  If  the  small-pox  pustules  or  vesicles  are  opened,  and 
if  iodine,  bromine,  or  nitric  acid  is  applied,  the  vesicle  or  pus- 
tule is  aborted ;  a  scab  is  immediately  formed,  it  soon  falls, 
and  if  the  whole  crop  or  the  major  part  of  the  crop  of  pus- 
tules has  been  aborted,  the  irritative  fever  is  also  aborted — the 
whole  constitutional  disturbance  abates,  and  immediate  con- 
valescence ensues. 

2d.  If  the  ulcerous  surfaces  of  the  tonsils,  in  scarlatina,  are 
brought  into  a  healthy  condition— nay,  more,  if  the  peculiar 
processes  are  arrested — nay,  still  more,  if  the  fluid  products  of 
the  ulcers  are  not  swallowed,  and  are  rendered  inert  by  the 
application  of  any  re-agent  which  breaks  up  their  chemical 
structure — the  constitutional  state  passes  oft". 

3d.  The  same  is  true  of  diphtheria.  In  regard  to  the  two 
last  mentioned  diseases,  reference  is  made  to  the  individual 
observations  of  the  reader.  Is  it  not  within  the  latter's  knowl- 
edge that  groping  empiricism  claims  no  blood  or  constitu- 
tional antidote,  specific  and  peculiar  to  either  of  the  blood 
states,  or  to  both?  She  supports  the  strength,  just  as  she  does 
in  typhus,  pysemia,  erysipelas,  and  other  dis6rders  of  "a  low 
type."  The  great  reliance  of  medicine  is  in  topical  remedies, 
the  mineral  acids,  chlor.  ferri,  chlor.  sodee,  &c.,  &c.  E"ow 
why?  Surely  if  the  local  state  is  but  the  local  expression,  or 
a  part  of  the  Ipcal  expression,  of  the  general  state  (for  so  the 
saying  goes),'  what  need  of  addressing  ourselves  to  the  mere 
outcrop  of  the  disease,  while  the  real  gravamen  is  in  the  blood 
behind  all  this  ?  Is  it  not,  rather,  that  empiricism,  a  sounder 
teacher  than  a  crude  philosophy,  has  somehow  felt  that  the 
constitutional  state  is  in  some  way  dependent  upon  the  local 
state  ?     "Whether  this  view  is  frankly  avowed  or  not,  the  idea 


HOSPITAL   GANGRENE,   ERYSIPELAS,   iC.  43 

stands  confessed  in  tlie  treatment  instituted ;  for  if  tlie  local 
treatment  does  not  embrace  tins  idea,  then  it  is  Llind  and 
purposeless  indeed.  True,  sometimes  the  local  processes  in 
both  scarlatina  and  diphtheria  produce  death  without  reference 
to  the  constitutional  state.  But  how  often  does  this  occur,  in 
comparison  with  the  frequency  of  death  through  the  increas- 
ing gravity  of  the  constitutional  symptoms  ? 

4tli.  Pyemia  is  the  constitutional  state  attending  upon,  or 
rather  occasionally  produced  by  wounds — e.  g.,  the  theory 
runs  that  patients  by  breathing  a  poisoned  atmosphere  ac- 
quire a  constitutional  or  blood  state,  eventuating  in  if  not 
consisting  of  pyaemia.  Kow  it  is  a  singular  circumstance  to 
begin  with,  that  no  one  has  pyremia  who  has  not,  somewhere 
in  his  body,  infiltrating  tissues,  filling  cavities,  or  flowing  from 
wounds  or  their  equivalents,  animal  fluids  whether  regarded 
as  exudates  without  morphological  change,  or  in  the  form  of 
cell-bearing  liquors.  Again,  it  is  within  the  knowledge  of 
every  medical  man  that  pyaemia  may  occur  independent  of 
suppuration,  in  connection  with  patho]9gical  processes  where 
the  warmest  of  Virchow's  admirers  fail  to  discover  any  cell- 
growth  or  cell-differentiation ;  nay,  more,  pyiemia  is  more  con- 
stant to  such  collections  as  are  found  in  exquisite  erysipelas, 
where  the  purulent  fluids  yield  to  the  most  searching  investi- 
gation neither  cells,  nor  nuclei,  nor  nucleoli — nay,  not  even  a 
connective  tissue,  corpuscle,  or  any  morphological  structure ; 
and  that  seemingly,  just  in  the  degree  that  the  morbid  pro- 
bid  products  approach  the  standard  of  true  pus  the  danger  ot 
pyaemia  grows  less.  Does  any  surgeon  anticipate  pyaemia  in  a 
so-called  healthy  suppurating  wound?  Does  he  not,  rather, 
when  healthy  suppuration  takes  place,  fetch  the  long  breath 
that  betokens  a  danger  passed — an  anxiety  relieved':'  I  ap- 
peal to  universal  experience. 

Yet  the  co-existence  of  pyaemia  with  the  conditions  men- 
tioned above  is  so  constant  and  invariable,  that  the  common 
instinct  of  medicine  associates  them  in  some  sort  of  relation 
of  cause  and  eflfect. 

More  than  this :  the  every  day  record  of  cases  shows  the  co- 


44  A   REPORT   ON 

existence  of  pyremia  ratlicr  with  ill-conditioned  discharges ; 
and  every  day's  record,  also,  sets  forth  the  amendment  on  the 
opening  of  confined  collections,  the  use  of  drainage  tubes,  the 
cleansing  of  the  parts,  &c.,  &c.  It  may  not  he  and  often  is  not 
stated  that  the  amendment  was  because  of  these  events,  but  the 
coincidence  occurs.  Still  more :  the  appended  cases,  noticed 
with  peculiar  reference  to  this  matter,  show  that  this  amend- 
ment coincides  (with  a  certainty  that  is  remarkable,  and  a 
rapidity  that  is  marvelous)  with  the  injection  into  the  infecting 
cavities  of  substances  which,  by  strong  coercion,  arrest  the 
putrefactive  motion,  destroy  the  products  of  putrefaction,  and 
render  putrescible  substances  non-putrescible. 

5th.  The  constitutional  condition  allied  to  hospital  gangrene 
is  a  sequent  state.  The  proof  of  this  statement  is  abundant 
in  the  record  of  cases  hereto  appended.  The  reader's  attention 
is  invited  to  the  constant  subsidence  of  the  general  or  consti- 
tutional disturbances  upon  the  arrest  of  the  gangrene,  a  sub- 
sidence constant,  marked,  and  immediate — most  emphatically 
pronounced  in  those  cases  where  the  bromine  was  used  undi- 
luted, and  carefully  applied.  The  attention  of  the  reader  is 
called  to  the  ameliorations  corresponding  with  the  amelioration 
of  the  gangrene,  to  the  constant  persistence  of  some  general 
expression  so  long  as  any  part  of  the  surface  was  untouched 
or  unchanged.  So  constant  was  the  loss  of  appetite,  debility, 
etc.,  to  the  lingering  of  the  gangrenous  process  in  limited  por- 
tions of  the  surface,  that  the  very  hue  and  expression  of  the 
face  betokened  the  fact,  told  the  story  to  the  observant  sur- 
geon. It  is  needless,  for  my  present  purpose,  to  multiply  ex- 
amples. I  desire,  here,  merely  to  convince  the  reader  that,  in 
some  diseases,  the  gravamen  of  the  constitutional  state,  if 

NOT  ITS  TOTALITY,  IS  PLAINLY  DUE  TO  THE  ABSORPTION  OF  THE  PRO- 
DUCTS OP  THE  LOCAL  PROCESSES.  I  Say,  absorpUon ;  for  it  is  not 
possible  to  conceive  of  any  other  process  by  which  the  whole 
organism  could  be  involved  to  the  extent  noticed. 

Now,  if  the  proposition  is  proven  in  regard  to  the  diseases 
in  question,  it  may  reasonably  be  asked  if  it  is  not  also  true 
of  other  disorders — if  it  is  not,  even,  within  certain  bounds,  a 


HOSPITAL   GANGRENE,    ERYSIPELAS,    &C.  45 

law  in  medicine?  I  confess  that  my  observations  lead  me  to 
think  it  is  one  of  broader  significance  and  wider  applica- 
tion than  is  generally  believed.  The  matter,  of  course,  needs 
a  full  investigation.  I  do  not  desire,  in  what  is  here  writ- 
ten, so  much  to  challenge  belief  as  to  invite  investigation. 
If  the  projected  law  is  a  true  one,  the  efiect  would  not  be  to 
revolutionize  but  to  simplify;  to  give  precision  to  methods 
now  vaguely  used ;  to  give  definite  views  and  purposes  to  re- 
medial measures ;  to  draw  attention  to  the  completeness  in  the 
efiect  of  traditional  remedies;  to  supplant  surmise  with  faith, 
and  indecision  and  doubt  with  confidence. 


CASES. 

[The  following  cases  are  selected  in  order  to  show,  amongst 
other  things,  the  varying  effects  of  the  difierent  modifications 
in  the  use  of  bromine,  and  to  give  the  reader  some  idea  of  the 
general  development  of  the  clinical  processes  elsewhere  recom- 
mended.] 

"Wilbur  F.  Nichols,*  corporal  company  B,  34th  Illinois,  was 
admitted  into  Ward  N'o.  1,  Hospital  No.  7,  January  15th,  1863, 
having  a  flesh  wound  upon  the  inner  aspect  of  the  left  leg,  in 
its  lower  third.  The  wound  was  made  by  a  miuie  ball,  had  its 
aperture  of  entrance  separated  from  that  of  exit  by  a  piece  of 
integument  about  two  inches  in  width.  The  wound  was  su- 
perficial.    The  edges  had  a  contused  and  pui-ple  appearance. 

January  20th,  well  marked  hospital  gangrene  made  its  ap- 
pearance. The  first  application  made  was  lint  saturated  with 
liq.  chlor.  soda.  This  application  was  continued  for  some  days, 
with  slight  improvement  in  the  cleanliness  of  the  wound.  The 
latter  was  covered  with  large,  greyish,  pulpy  sloughs,  and  a 

*  Nichols's  case  was  the  first  one  of  hospital  gangrene  to  which  the  bromine  was 
applied. 


46  A  REPORT  ON 

scrofulous  looking  pus,  emitting  a  foul  odor ;  it  is  about  five 
inches  in  length  in  its  largest  diameter.  The  tendons  are  to  be 
plainly  seen,  as  well  as  the  internal  saphena,  exposed,  indu- 
rated, filled  with  coagulated  blood,  and  sloughing  throughout 
the  whole  extent  of  the  ulcer.  The  tibia  and  fibula  are  bare, 
the  former  for  two  and  a-half  inches.  Constitutional  symp- 
toms are  prostration,  restlessness,  sleeplessness,  and  loss  of  ap- 
petite. The  local  treatment  has  been,  up  to  date  February 
10th,  mur.  tinct.  ferri,  charcoal,  and  cinchona  poultices,  tar 
water,  and  dilute  nitric  acid.  Constitutional  treatment  has 
consisted  of  wine,  quinine,  egg-nog,  and  generous  diet.  This 
morning,  on  removing  the  dressings,  an  arterial  jet  followed, 
which  was  stopped  by  torsion.  There  seems  now  nothing  left 
but  amputation.  Although  the  patient  is  willing  to  submit, 
the  operation  holds  out  but  little  hope,  on  account  of  the  great 
prostration  present. 

Surgeon  Goldsmith,  U.  S.  V.,  Medical  Director,  was  called 
upon  this  morning,  in  order  to  obtain  his  consent  to  the  opera- 
tion. He  ordered  the  treatment  by  bromine,  to  be  commenced 
by  injecting  it  into  the  wound  in  all  its  parts,  particularly  un- 
der the  raised  edges  of  the  skin.  In  the  meanwhile  the 
sloughing  had  extended  in  the  cellular  tissue  from  the  ankle 
nearly  to  the  knee.  The  foot  was  hugely  swollen.  The 
wound  is  covered  with  thin,  difliuent,  greyish,  fetid  sloughs  of 
skin,  cellular  tissue,  and  muscle.  A  dirty  yellowish  fluid 
oozes  from  the  cellular  planes.     The  tibia  is  bare  about  three 

inches. 

1^ — ^Bromine,    gtt.  xx. 
Alcohol,  3j. 

M. 
To  be  applied  every  four  hours,  day  and  night. 
February  11th.    The  wound  looks  cleaner  this  morning  than 
has  been  seen  for  a  long  time.     Sloughs  not  so  adherent,  ulcer 
is  becoming  more  sensitive ;  continue  treatment. 

February  12th.  The  improvement  in  the  wound  is  marked : 
patient  feels  better  in  every  way ;  appetite  and  spirits  better. 


HOSPITAL   GANGRENE,   ERYSIPELAS,   iC.  47 

J^ — Bromine,   gtt.  xl. 
Alcohol,  3j. 

M.  Apply  as  before. 
February  13th.  Whole  ulcer  presenting  a  healthy  granula- 
ting surface ;  appetite  and  all  constitutional  symptoms  very 
much  improved.  The  bromine  was  now  suspended  on  account 
of  the  pain.  The  wound  has  continued  to  granulate  until,  at 
the  present  date,  March  7th,  it  is  on  a  level  with  the  surface. 
Patient  is  daily  gaining  in  strength,  and  often  speaks  of  the 
substance  which  he  thinks  saved  his  leg  and  life. 

[  Condensed  from   the  report    of  Medical  Cadet  Larabco.] 


Kelson  Koroson,  private  company  B,  10th  Wisconsin  Vol- 
unteers, was  admitted  into  Ward  1,  Hospital  No.  7,  Louisville, 
Ky.,  January,  15th,  1863,  at  9  A.  M.,  having,  in  battle  at  Mur- 
freesboro,  Tennessee,  received  a  flesh  wound  upon  the  inner 
aspect  of  the  lower  third  of  the  right  thigh — apertures  of  exit 
and  entrance  near  together.  The  wound  has  a  contused  and 
purple  appearance,  as  have  the  tissues  for  several  inches  around. 
General  health  good. 

January  20th.  Gangrene  made  its  appearance  February 
17th.  The  wound  is  now  four  inches  long,  three  inches  wide, 
and  one  and  a  half  inches  deep.  The  topical  applications  have 
been  warm  water  dressings,  sol.  acet.  zinc,  tr.  ferri  chlor.,  tr. 
arnicse.  Patient  has  had  frequent  chills,  diminished  appetite ; 
has  taken  cathartics,  quinine,  Dover's  powder,  and  generous 
diet.  Large  sloughs  have  been  removed  every  day.  The  skin 
is  undermined  to  the  extent  of  two  inches  in  every  direction. 
Commenced  to-day  to  inject  the  ulcer  with  tinct.  of  bromine, 
as  in  the  case  of  Xichols,  and  in  the  meanwhile  bromine  vapor 
was  applied  in  the  usual  manner. 

February  18th.  Morning  visit.  The  sloughs  are  of  a  yel- 
lowish color  and  easily  detached ;  wound  is  now  sensitive,  and 
shows  more  signs  of  vitality  than  have  been  seen  before.  Con- 
tinue bromine.     Bromine  causes  pain. 


48  A  REPORT   ON 

February  lOtli.  This  morning  patient  says  lie  feels  better 
than  he  has  'for  a  long  time ;  wants  something  good  to  eat. 
Sloughs  have  all  disappeared  from  the  ulcer ;  a  healthy,  laud-^ 
able  pus  is  secreted ;  granulation  may  be  seen  commencing, 
foul  odor  gone ;  whole  surface  a  lively  red  color.  From  this 
date  the  recovery  was  rapid. 

It  is  proper  to  state  that  in  all  the  cases  coming  under  my 
observation  in  which  bromine  has  been  used,  simultaneous- 
ly with  the  removal  of  the  sloughs,  by  the  arrest  of  the  gan- 
grene, the  appetite  and  general  health  of  the  patient  has  im- 
proved. 

[Condensed  report  by  Larabee,  Medical  Cadet.] 


J.  "W".  Bennet,  private,  company  H,  44th  Tenn.  infantry,  C. 
S.  A.:  wound  inflicted  by  a  fragment  of  a  shell  at  the  battle 
of  Murfreesboro,  December  31st,  1862.  The  inner  aspect  of 
the  middle  third  of  left  thigh  torn  away,  with  much  contusion 
of  the  surrounding  tissues.  Sloughing  and  gangrene  contin- 
ued until  the  ulcer  covered  a  space  of  eight  inches,  longest  di- 
ameter, and  five  inches,  shortest  diameter,  the  tissues  being 
destroyed  an  inch  in  depth.  The  fleshy  part  of  the  lower  bor- 
der of  the  rectus  femoris,  the  belly  of  the  sartorius,  the  adduc- 
tor magnus  were  involved  in  the  sloughing,  and  the  long  inter- 
nal saphenous  vein  was  exposed  throughout  the  extent  of  the 
ulcer  until  it  sloughed  away.  Admitted  for  treatment  Feb. 
15th,  1863.  Age  27,  a  farmer,  height  5  feet  6  inches,  born  in 
Middle  Tennessee ;  complexion  dark;  for  the  last  six  years  suf- 
fered greatly  with  his  breast;  temperament,  n6rvous.  Has  ir- 
ritable stomach,  furred  tongue,  fever,  constipated  bowels,  with 
great  restlessness.  Ordered  saline  draughts  until  bowels  ope- 
rated ;  wound  dressed  with  flaxseed  poultice ;  sulph.  morphias, 
1  gr.,  at  bed-time. 

February  16th.  Stomach  still  irritable;  tongue  moist  but 
pale,  fur  cleared  off;  bowels  moved  twice  during  the  night; 
slept  well  and  feels  refreshed ;  wound  looks  and  smells  horrid- 


HOSPITAL   GANGRENE,   ERYSIPELAS,   &C.  49 

ly.  Great  quantities  of  sloiigli  removed  by  poultice  and  scis- 
sors. Dressed  witli  lint  saturated  in  bromine,  1  oz.,  alcohol 
five  oz.  Also  tbe  above  solution  injected  into  and  all  over  the 
ulcer  without  producing  any  pain.  Nothing  but  milk  and 
lime  water  retained  in  stomach.  Egg-nog,  milk  punch,  whis- 
ky, and  brandy  toddy  rejected,  as  also  sherry  wine. 

17th.  Had  slept  well  after  taking  1  gr.  morph.  the  night 
previous ;  stomach  still  irritable,  retaining  little  but  milk  and 
lime  water,  with  some  cold  chicken  broth ;  ulcer  looking  and 
smelling  slightly  better  ;  boAvels  moved  once ;  some  fever  still. 
Bromine  treatment  continued  to  ulcer,  the  dressings  envel- 
oped in  oiled  silk.  Saline  draughts  continued  at  intervals  of 
three  hours.  Barley  water  (to  satisfy  intense  thirst)  in  small 
quantities.     Sinapisms  over  epigastrium. 

18th.  Stomach  less  irritable,  fever  slight,  ulcer  decidedly 
improving.  Bowels  moved  once.  Bromine  treatment  contin- 
ued. Sulph.  morph.  one-half  grain  every  four  hours;  light 
diet,  with  corn-bread,  allowed. 

19th.  All  symptoms  improved;  ulcer  tolerable  in  center, 
deep  sloughs  around  the  edges.  Bromine  treatment  continued- 
Light  diet,  with  corn-bread  and  Sherry  wine,  retained  ajad 
continued.  The  patient  feels  better,  this  being  the  first  time 
he  has  so  expressed  himself. 

20th.  Sloughs  still  adhere,  and  their  removal  produces 
nausea  without  pain.  Bromine  produces  slight  tinglings,  but 
no  pain.     Continue  treatment. 

21st.    No  change. 

22d.  Sloughs  still  deep,  but  their  removal  produces  but 
slight  nausea  with  considerable  pain.     Continue  treatment. 

23d.  The  ulcer  very  painful.  Indisposition  on  the  part  of 
patient  to  have  it  dressed.  Sloughs  around  the  edges  deep 
and  ugly ;  fever,  irritable  stomach  returned,  with  loss  of  appe- 
tite and  profuse  perspiration.  Bromine  treatment  continued. 
Tinct.  chlor.  ferri,  gtt.  xx.,  every  four  hours,  sulph.  morph.. 
ss.  grain  every  3  hours.  Sinapism  over  the  epigastric  region. 
Chloroform  administered  whilst  applying  the  bromine. 
4 


50  A   REPORT   ON 

24tb.  No  change  except  stomach  less  irritable,  perspiration 
not  so  profuse.  Our  Medical  Director,  Dr.  Goldsmith,  on  his 
visit  to-day,  was  kind  enough  to  dissect  off  the  sloughs,  and 
apply  his  solution  (bromine  ten  parts,  water  ten  parts,  bromide 
of  potassium  two  and  a  half  parts),  with  a  wooden  spatula,  di- 
rectly to  the  parts  that  required  it.  Light  diet  and  wine  was 
continued. 

25th.  Sloughs  and  softening  disappearing.  Continue  treat- 
ment. 

26th.  Still  improving,  only  two  or  three  points  to  be  touched 
with  the  bromine.  Appetite  good,  stomach  retentive,  perspira- 
tion natural,  tongue  clean,  fever  absent ;  takes  egg-nog  freely, 
chicken  soup,  baked  apples,  corn-bread,  &c. 

27th.  Most  beautifully  filling  up  with  the  nicest  granula- 
tions, no  points  visible  for  the  action  of  the  bromine.  Simple 
cerate  dressings  ordered.  From  this  time  the  recovery  was 
uninterrupted,  rapid,  and  complete. 

A.  T.  C.  WORTIIIXGTOX,  A.  A.  S.,  U.  S.  A. 


J.  E.  Mortimer,  co.  B.,  5th  Arkansas,  C.  S.  A.,  wounded  by 
a  conical  ball,  December  31st,  1862,  at  the  battle  of  Stone 
River,  Tennessee,  was  admitted  February  15th,  1863 ;  age 
twenty-four  years,  height  five  feet  four  and  a  half  inches, 
complexion  fair,  strumous  diathesis.  The  ball  entered  above 
tuberosity  of  ischium,  left  thigh,  and  passed  out  and  over  the 
great  trochanter.  The  point  of  exit,  larger  than  the  point  of 
entrance,  was  separated  from  the  latter  by  a  band  of  integ- 
ument over  the  track  of  the  ball ;  this  continued  to  slough 
until  the  two  apertures  were  united  in  one  large  ulcer,  up- 
wards of  five  inches  in  diameter.  The  sloughing  involved 
the  glutei  muscles  and  the  adipose  tissue.  The  trochanter 
major  was  denuded  of  its  periosteum.  The  patient  exhibited 
the  following  symptoms  on 

Feb.  15th.  Delirium,  vvith  well  marked  characters  of  hec- 
tic.    The  wound  was  dressed  with  the  usual  water  dressings. 


HOSPITAL    GANGRENE,    ERYSIPELAS,    &C.  51 

with  the  internal  use  of  saline  draughts,  cold  water  to  the 
head,  &c. 

16th.  Not  much  better.  Liberal  diet,  stimulants,  viz :  egg- 
nog  and  milk  punch,  in  pint  quantities,  daily.  Warm  water 
dressings. 

17th,  18th,  and  19th.     Treatment  continued. 

20th.  Wound  looking  very  bad.  Bromine  3j.,  alcohol  3iv., 
applied  every  two  hours  by  saturating  lint  after  well  injecting 
the  whole  surface  with  the  above  solution.     Liberal  diet. 

21st.  Improvement.  Occasional  delirium,  fever  not  so  in- 
tense, wound  looking  improved  in  the  center,  sloughing  go- 
ing on  around  the  edges.     Treatment  contined. 

22d.     Treatment  continued. 

23d.  Dissected  all  the  old  sloughs  away,  and  applied  the 
comp.  sol.  bromine,  at  the  suggestion  of  Dr.  Goldsmith,  with 
a  wooden  spatula,  directly  to  all  the  parts  having  a  sloughing 
tendency. 

24th.  The  greatest  improvement  imaginable,  viz  :  no  delir- 
ium, no  fever,  appetite  good,  is  cheerful,  and  feels  like  getting 
well  at  once ;  wound  granulating  finely ;  everything  going  on 
well.     Treatment  continued. 

25th.  Still  improving.  Treatment,  warm  water  dressings. 
"Wound  filled  with  fumes  of  bromine. 

26th.     Still  doing  well.     Same  treatment  continued. 

27th.  Wound  nearly  filled  up  with  the  granulations  ;  gen- 
eral health  very  good.  From  this  date  convalescence  pro- 
gressed rapidly.     The  exposed  bone  gramllated  freely. 

A.  T.  C.  WORTHINGTOIT, 
A.  A.  S.,  U.  S.  A. 


Milo  F.  Baxter,  sergeant,  company  F,  11th  Kentucky,  in 
good  health,  was  wounded  in  the  battle  of  Murfreesboro,  Jan- 
uary 3d,  1863,  the  ball  passing  through  the  fleshy  part  of  the 
left  arm,  about  three  inches  above  the  elbow,  leaving  a  space 
of  about  two  inches  between  the  point  of  entrance  and  exit. 
He  was  placed  at  convalescent  barracks,  where  the  wound  had 


52  A  REPORT   ON 

received  but  little  attention.  Admitted  February  15tli.  Con- 
dition when  admitted :  Patient  feeble,  tongue  coated  and  dry, 
bowels  constipated,  pulse  115,  appetite  not  good,  restless  at 
nigbt. 

The  wound  presented  two  ulcers,  about  an  inch  in  diameter 
and  an  inch  apart,  covered  with  greyish,  thick,  and  rather  firm 
sloughs.  Twenty-four  hours  after,  the  intervening  space  had 
been  destroyed  by  the  disease,  and  the  two  ulcers  became 
one,  then  about  three  and  a  half  inches  in  length  and  two  and 
a  half  wide,  covered  with  the  same  firm,  greyish  matter,  and 
exceedingly  offensive.  The  edges  of  the  ulcer  were  red  and 
tender.  The  patient  suffered  great  pain.  Treatment  and  pro- 
oress :  for  three  days  the  ulcer  was  treated  with  warm  water 
dressings,  and  continued  to  extend.  On  the  morning  of  the 
19th  bromine  was  first  applied — about  one  drachm  to  a  pint 
and  a  half  of  water — with  but  little  or  no  improvement.  The 
nicer  continued  to  extend,  burrowing  under  the  shin,  and  the 
thick  sloughs  still  remaining.  On  the  21st  the  sloughing  invad- 
ed the  brachial  artery,  causing  profuse  and  almost  fatal  hemor- 
rhage. The  hemorrhage  was  arrested  only  by  tying  the  vessel, 
which  was  done  about  an  inch  above  the  border  of  the  ulcer. 
By  the  23d,  two  days  after  the  artery  was  tied,  the' sloughing 
had  extended  to  that  wound  also,  and  great  fear  was  entertain- 
ed that  hemorrhage  might  again  occur.  At  this  time  the  ulcer 
had  attained  the  size  of  about  five  inches  in  length,  and  three 
and  a  half  in  width,  the  patient  very  feeble,  pulse  140  per  min- 
ute, tongue  dry  and  coated  with  a  dark  brown  coat.  It  was 
then  resolved  to  try  a  strong  solution  of  bromine,  applied  to 
the  sloughs,  as  well  as  to  the  brachial  artery  which  had  been 
tied,  and  to  the  parts  adjacent,  the  whole  ulcer  to  be  covered 
with  lint  saturated  with  a  solution  of  one  part  of  the  conip.  sol. 
bromine  to  sixteen  of  water.  This  dressing  was  repeated  every 
four  hours,  good  diet  and  ale  were  prescribed,  and  an  opiate  at 
night.  Under  this  treatment  the  patient  improved  rapidly, 
the  slough  separating,  leaving  the  surface  beneath  granulating. 
The  ligature  held,  and  during  the  granulating  process  the  tied 
extremity  of  the  brachial  could  be  seen  in  situ,  covered,  like 


HOSPITAL   GANGRENE,   ERYSIPELAS,   &C.  53 

the  otlier  tissues,  witli  granulations.  Tlie  bromine  was  diluted 
as  the  sloughing  ceased  and  the  parts  became  more  sensitive. 
On  the  5th  of  March  the  ulcer  presented  a  healthy  appearance, 
entirely  free  from  gangrenous  matter,  filling  up  rapidly  with 
granulations,  and  already  contracting  in  size. 

March  12th.     Improvement  continues  without  interruption. 

The  character  of  the  ulcer,  the  rapidity  with  which  it 
extended,  the  great  constitutional  disturbance,  and  especial- 
ly the  exhausting  hemorrhage  rendering  it  necessary  to  tie  the 
artery,  all  combined  to  make  this  an  interesting  and  instructive 
case.  From  a  somewhat  close  observation  of  this  case  (it  was 
not  directly  under  my  charge)  I  feel  assured  that  the  slough- 
ing might  have  been  arrested  sooner,  but  for  some  fault  in  ap- 
plying the  bromine.  It  was  not  well  understood  then,  if  indeed 
it  is  yet,  what  is  the  best  mode  of  applying  the  remedy,  and 
in  what  strength ;  and  I  am  satisfied  that  it  was  not  efficiently 
applied  in  the  earlier  part  of  the  case.  The  solution  used  was 
not  strong  enough,  and  the  dressing  was  not  applied  often 
enough. 

It  is  worthy  of  notice  how  soon  the  general  condition  of  the 
patient  improved  after  the  local  disease  was  arrested.  This 
could  not,  I  think,  be  attributed  to  the  general  treatment,  al- 
though that  unquestionably  had  a  share  in  the  improvement. 
The  rapid  improvement  in  the  appearance,  appetite,  pulse, 
tongue,  and  nervous  condition  of  the  patient,  so  soon  after  the 
spread  of  the  gangrene  was  arrested,  could  not  be  mistaken  for 
the  cause  of  the  improvement  in  the  ulcer. 

J.  A.  DOUGHERTY,  A.  A.  S., 

March  12th,  1863.  Hospital  No.  3. 


Henry  Herman,  private,  company  A,  6th  Ohio,  previously 
in  good  health,  received  a  flesh  wound  (gun  shot),  December 
31st,  1862,  at  Stone  river,  Tenn.,  the  ball  entering  to  the  left 
and  lower  extremity  of  the  sacrum,  passing  downwards  and 
outward,  and  emerging  about  five  inches  from  the  point  of 
entrance.     The  wound  did  well  for  about  four  weeks,  when 


54  A  REPORT   ON 

erysipelas  set  in,  attended  with  considerable  tumefaction,  ex- 
tending to  the  left  groin,  and  resulting  in  hospital  gangrene. 
The  patient  was  admitted  to  Hospital  No.  3  about  ten  days 
after  gangrene  set  in,  viz :  February  15th.  Condition  when  ad- 
mitted: Patient  considerably  emaciated,  feeble,  pulse  110  per 
minute  and  feeble,  appetite  not  good,  tongue  coated  and  rather 
dry,  bowels  constipated,  restless  at  night. 

In  the  left  groin,  just  above  Poupart's  ligament,  was  an  ulcer 
about  six  inches  in  length,  and  four  and  a  half  inches  wide, 
and  at  least  three-fourths  the  thickness  of  the  abdominal  walls 
in  depth.  Sloughing  was  still  going  on,  the  ulceration  bur- 
rowing under  the  border  of  the  skin,  which  was  of  a  dark, 
dead  appearance.  The  surface  of  the  ulcer  was  covered  with 
a  dirty  greyish  slough,  and  exceedingly  oifensive.  The  slough- 
ing had  exposed  one  of  the  inguinal  glands,  which  stood  out 
from  the  surface  as  large  as  a  partridge  egg. 

Treatment.  For  two  days  the  ulcer  was  treated  with  warm 
water.  On  the  17th  applied  bromine,  in  weak  solution,  (brom. 
3ss.,  ether  5  v.),  by  saturating  a  piece  of  patent  lint  with  the  so- 
lution, and,  after  first  covering  the  ulcer  with  dry  lint,  laying 
it  on,  then  enveloping  the  whole  with  oiled  silk  to  prevent 
the  escape  of  the  vapor. 

On  the  18th  the  bromide  of  potassium  was  obtained,  and  the 
comp.  sol.  was  prepared  and  us*ed  in  the  subsequent  dressing. 
This  solution,  diluted  more  or  less  as  the  patient  could  bear 
without  great  pain,  generally  about  one  part  to  twenty-four  of 
water,  was  applied,  as  a  wash,  by  means  of  saturated  pieces 
of  lint,  as  often  as  every  four  hours  until  the  twenty-sixth, 
about  nine  days.  Good  diet  and  ale  were  prescribed,  with 
aperients  as  often  as  the  condition  of  the  bowels  required. 

For  the  first  twenty-four  hours,  whilst  the  etherial  solution 
was  being  used,  there  was  little  or  no  improvement.  After 
the  comp.  sol.  was  resorted  to,  the  improvement  was  well 
marked  in  six  hours,  and  continued  without  interruption  until 
at  present. 

March  9th.  The  ulcer  is  filled  up  with  healthy  granulations, 
and  has  contracted  to  less  than  half  its  original  size.     On  the  3d 


HOSPITAL   GANGRENE,   ERYSIPELAS,   &C.  55 

of  Marcli  a  deep  erysipelatous  redness  was  observed,  extend- 
in  o*  from  the  border  of  the  ulcer  backwards.  This  was  dressed 
with  a  weak  solution  of  bromine — one  part  of  the  comp.  sol. 
to  sixty  of  water.  In  twenty-four  hours  it  had  disappeared. 
This  was  the  only  deviation  from  a  uniform  recovery  in  the 

case 

J.  A.  DOUGHERTY,  A.  A.  S.,  Hospital  No.  3. 

March  12th,  1863. 


Linuieus  0.  Smith,  aged  about  31  years,  was  wounded  at  the 
battle  of  Murfreesboro,  December  31st,  1862,  by  a  musket  ball 
entering  the  inner  and  upper  part  of  the  left  leg,  passing 
obliquely  downwards  and  outward,  traversing  the  gastrocne- 
mii  muscles,  and  emerging  about  six  inches  from  the  point  of 
entrance,  having  slightly  grazed  the  tibia,  but  left  the  princi- 
pal vessels  intact.  Was  admitted  to  General  Hospital  No.  8, 
Louisville,  Kentucky,  January  14th,  1863,  with  much  fever, 
furred  tongue,  deranged  secretions  generally.  The  wounded 
parts  much  swollen,  very  painful,  and  discharging  a  sanious 
and  offensive  pus.  A  few  days  subsequently  the  parts  became 
gangrenous,  involving  the  cellular  tissue,  and  forming  sinuses 
in  the  gastrocnemii,  covered  with  dark,  thick,  adherent  slough, 
the  stench  of  which  it  was  almost  impossible  to  remove  from 
the  ward. 

The  treatment  had  consisted  of  simple  water  dressings — 
with  the  internal  exhibition  of  quinine,  iron,  alteratives,  and 
a  nourishing  diet;  but  the  gangrene  remained  unchecked 
nevertheless. 

Surgeon  M.  Goldsmith,  Medical  Director,  now  ordered  an 
application  of  bromine  to  be  made ;  and  having  removed  the 
dark,  fetid,  and  adherent  sloughs,  with  scalpel  and  forceps, 
inire  bromine  was  applied  to  the  surface,  giving  much  smarting 
for  some  fifteen  or  twenty  minutes.  An  emoUient  poultice  was 
applied,  and,  on  its  removal  a  few  hours  after,  a  very  sensible 
change  was  observed  in  the  character  of  the  discharge,  and 
especially  in  the  correction  of  the  offensive  odor.     Twenty- 


56  A  REPORT   ON 

four  liours  after  the  first  application  of  the  bromine  a  second 
application  was  made  to  the  parts,  this  time  Smith's  sol.  This 
was  injected  freely  into  the  sinuses,  and,  after  a  few  moments^ 
pressed  out  again  gently  with  the  hands,  and  the  poultice  ap- 
plied as  before. 

In  forty-eight  hours  after  the  first  application  of  bromine,  the 
gangrene  was  entirely  arrested,  all  offensive,  putrid  odor  re- 
moved, and  the  parts  discharging  a  much  improved  character  of 
pus.  A  weaker  solution  of  bromine,  3ss.  water  3viii.,  was  ap- 
plied daily  as  a  wash  for  three  days,  and  the  parts  were  dressed 
with  ung.  resin.  Tonics  and  nourishing  diet,  with  wine,  ale, 
beef  tea,  &c.,  were  continued  as  before.  A  very  marked  change 
in  the  general  health  and  appearane  of  the  patient  occurred 
soon  after  the  first  application  of  the  bromine.  The  night 
sweats  and  the  diarrhea,  previously  existing,  ceased  directly, 
tongue  cleared  ofl',  appetite  increased,  and  general  expression 
and  appearance  improved.  The  wound  is  now,  February  1st, 
covered  with  healthy  granulations,  and  is  rapidly  closing.  His 
general  health  is  good,  and  he  is  doing  well  in  every  respect. 
This  was  a  bad  and  very  unpromising  case  of  hospital  gangrene ; 
and  the  marked  and  rapid  change  in  the  arrest  of  the  gan- 
grene, the  correction  of  the  fetor,  and  the  general  improve- 
ment of  the  patient,  were  particularly  gratifying  and  instructive. 

[Signed,]  FRAKKLm  lEISH, 

Surgeon  11th  Fa.  Vols., 
In  charge  of  Hospital  No.  8,  Louisville,  Kg. 


Wm.  Murphy,  of  co.  I,  78th  Pennsylvania  Ecgiment, 
aged  24  years,  entered  this  Hospital  on  the  28th  of  February, 
1863.  He  was  wounded  at  the  battle  of  Murfreesboro  with  a 
conical  ball,  passing  through  the  right  foot,  fracturing  the 
metatarsal  bones  of  the  second,  third,  and  fourth  toes,  portions 
of  Avhich  bones  had  been  removed  at  Murfreesboro.  On  enter- 
ing tliis  hospital  his  wound  was  in  a  healthy  condition,  his  gen- 
eral health  was  good,  and  remained  so,  until  the  15th  of  March, 


HOSPITAL   GANGRENE,   ERYSIPELAS,   &C.  57 

when  the  wound  began  to  present  a  gangrenous  appearance, 
being  of  a  dark,  purplish,  grey  color,  and  of  an  offensive  odor. 
On  examining  the  pulse  I  found  it  beating  one  hundred  and 
twenty  to  the  minute.  Skin  hot  and  dry,  tongue  furred, 
breath  of  a  saccharine  odor,  bowels  constipated,  no  appetite, 
and  an  aversion  to  animal  diet. 

Made  an  application  of  the  solution  of  bromine,  full  strength, 
(Wilson  &  Peter's  solution),  by  means  of  hair  pencil,  three 
times  a  day,  and  then  applied  cinchona  poultice.     Gave 
^: — Chlorate  of  potash. 

Calomel,      aa.  grs.  x. 

Ipecac  pulv.,  grs.  x. 

Opii  "  grs.  ij.  ss. 

Divid.  in  chart  x.     One  every  three  hours. 

Also — 

?r — Quinine  sulph., 

Ferri  sulph.,  aa.  gr.  xxiv. 
Bivid.  in  ch.  xii.  One  before  each  meal.  Extra  diet. 
March  16th.  Great  improvement  in  the  appearance  of  the 
wound,  pulse  regular,  skin  moist,  tongue  cleaning  off,  appetite 
improving,  bowels  open.  Continue  the  application  of  bro- 
mine, and  cinchona  poultice.  Quinine  and  iron,  as  on  the  day 
before.  Continued  this  treatment  for  three  days,  at  the  end 
of  which  time  the  wound  presented  a  healthy  character,  and 
the  general  health  was  entirely  restored. 

J.  S.  LOGAK,  A.  A.  S., 
General  Hospital  No.  12,  Louisville,  Ky. 


Ery  W.  Taylor,  company  C,  19th  Michigan,  wounded  at 
the  battle  of  Spring  Hill  by  a  musket  ball,  w^hich  entered  on 
the  left  side  and  anterior  portion  of  the  neck,  passing  under 
the  sterno-cleido-mastoid  muscle  between  the  external  jugu- 
lar vein  and  carotid  artery,  making  its  exit  near  the  anterior 
border  of  the  trapezius  muscle,  four  inches  from  its  attach- ' 
ment  to  the  occipital  protuberance.  He  was  admitted  to  Gen- 
eral Hospital  1^0.  11,  Louisville,  Kentucky,  April  15th,  forty 


68  A  REPORT   ON 

days  after  the  reception  of  tlie  wound.  The  point  of  entrance 
had  entirely  healed,  but  that  of  its  exit  was  a  deep,  indolent 
ulcer,  smooth,  clean  edges,  about  the  size  and  shape  of  a  large 
almond.  His  constitutional  condition  was  far  below  par,  yet 
he  was  able  to  walk  about  and  go  to  the  table  for  food.  He 
was  ordered  a  nutritious  diet,  with  wine,  and  the  wound  dressed 
with  -citrine  ointment. 

April  19th.  Wound  dark  and  indolent,  and  the  odor  fetid; 
pulse  100,  tongue  dry  with  a  thin  white  coat  in  the  center  and 
red  edges,  some  diarrhea,  a  severe  cough ;  sleeps  poorly  and 
has  night  sweats ;  a  charcoal  and  yeast  poultice^  was  applied 
to  the  wound;  quinine  and  opium  in  full  doses,  with  ale,  were 
given  thrice  daily. 

April  20th.  Wound  greatly  enlarged,  edges  ragged,  under 
which  pus  of  a  most  oifensive  character  burrows,  a  deep  slough 
showing  itself  over  the  whole  surface  of  the  sore,  pulse  110, 
cheeks  red,  tongue  dry,  skin  harsh  to  the  feeling,  though  the 
night  sweats  continue.  Bromine  was  now  applied,  3ij.  of  bro- 
mine, 3j.  of  alcohol,  and  water  q.  s.  to  make  four  ounces  of 
the  mixture. 

April  21st.  The  wound  has  grown  to  be  three  by  two  inches 
in  size,  tilled  with  ash  colored  sloughs,  and  the  odor  intolera- 
ble; pulse  110,  cheeks  red,  tongue  dry  and  white  coat  in  cen- 
ter ;  stools  reduced  in  regard  to  frequency,  yet  of  a  dark  color 
and  offensive  odor.     The  same  application  as  the  day  before. 

April  22d.  The  sloughing  enlarged  the  wound  very  much, 
leaving,  stretched  across  its  center,  a  portion  of  the  skin  black- 
ened and  dead ;  this,  with  the  edges  of  the  wound,  was  trim- 
med off  with  scissors.  The  slough  covering  the  center  of  the 
sore  was  deep,  and  whitish  in  color.  Patient  reduced  very 
much;  pysemic  symptoms  of  a  most  aggravating  character, 
pulse  105,  tongue  dry  and  red,  stools  same  as  the  day  before. 

Citr.  ferri  et  quini?e,  gr.  v.,  after  each  meal,  or  three  times  a 
day,  was  ordered.  The  bromine  was  applied,  5j.  to  3j.  of  alco- 
hol. 

April  23d.  The  surface  of  the  wound  extends  three  by  four 
inches  in  size,  under  the  ragged  edges  of  which  the  fetid  pus 


HOSPITAL   GANGRENE,   ERYSIPELAS,   &C.  59 

burrows  to  the  extent  of  au  inch  and  a  half.  The  surface  of 
the  wound  still  covered  with  ragged,  dark  slough,  acrid  and 
offensive.  Bromine,  nearly  full  strength,  was  now  used  over 
the  whole  surface  of  the  wound,  and  injected  well  beneath  its 
edges,  after  which  the  wound  was  dressed  with  simple  cerate. 
No  change  to  be  noticed  in  the  patient's  physical  condition. 

April  24th.  Discharge  not  so  great  from  the  wound,  the 
fetor  disappeared,  and  the  sloughs  begin  to  detach  themselves. 
Patient  feels  better. 

April  25th.  One-half  of  the  sloughs  have  come  away ;  pulse 
95,  tongue  more  clean,  appetite  good,  slept  well  last  night,  the 
night  sweats  ceased. 

May  3d.  Sloughs  all  gone,  the  discharges  bearing  a  natur- 
al character.  The  granulations  look  red  and  lively.  Up  to 
this  time  the  bromine  has  been  used  continuously,  but  was 
this  day  discontinued,  and  a  dressing  of  simple  cerate  was 
thought  sufficient;  pulse  90,  tongue  clean,  bowels  nearly 
natural,  appetite  good,  sleeps  well.  Though  he  is  weak,  the 
patient  expresses  himself  as  feeling  very  well.  From  this  last 
date  the  wound  rapidly  assumed  the  most  healthy  character, 
and  nature,  in  her  most  rapid  and  beautiful  manner,  com- 
menced repairing  the  parts,  while,  at  the  same  time,  the  con- 
stitutional condition  of  the  patient  was  rapidly  improving.  The 
first  thing  to  be  remarked  in  this  case  was  that  the  constitu- 
tional symptoms  of  pysEmia  developed  themselves  before  the 
local  symptoms  of  gangrene.  The  second :  the  remarkably 
rapid  manner  which  the  destructive  process  in  the  wound  went 
on.  Third  :  that  when  a  comparatively  weak  solution  was  ap- 
plied, no  good  accrued,  but  that  when  the  bromine  was  applied 
nearly  full  strength,  not  only  did  the  sloughing  immedi- 
ately cease,  as  also  the  fetid  odor,  but  the  dead  por- 
tions began  to  detach  themselves,  and,  moreover,  within 
thirty-six  hours,  the  pytemic  symptoms  began  to  cease.  To 
Dr.  Strew,  the  surgeon  in  charge,  the  reporter  is  indebted  for 
many  valuable  and  timely  suggestions. 

H.  E.  VAN  NOOKi;  A.  A.  S.,  U.  S.  A., 
General  Hospital  No.  11,  Louisville,  Ky. 


60  A   REPORT   ON 

Josepli  W.  Ricliardson,  a  private  of  co.  D.,  3d  Kentucky 
Infantry,  was  transferred  from  Hospital  No.  5,  Xasliville,  Ten- 
nessee, to  this  hospital,  March  12th,  1863.  At  the  time  of  his 
admission  he  was  suffering  from  pain  in  the  left  temple,  im- 
paired sight  of  the  left  eye,  constipation  of  the  bowels,  and  a 
feeling  of  general  prostration — the  effect,  as  he  supposed,  of  an 
attack  of  erysipelas  of  the  face  and  n^ck  which  he  had 
about  the  latter  part  of  December,  whilst  on  duty  as  nurse 
at  Nashville.  He  was  treated  by  Dr.  Fischer,  under  whose 
charge  he  was  placed,  and  by  the  1st  of  June  was  so  far 
improved  as  to  be  able  to  do  guard  duty  at  the  hospital. 
He  complained  occasionally,  however,  of  vertigo,  feeling,  as  he 
said,  as  if  he  was  half  drunk.  July  5th,  about  5  o'clock,  P. 
M.,  while  walking  in  the  yard,  he  fell  down  in  something  like 
an  epileptic  fi  t,  and  was  carried  into  the  ward,  where  he  re- 
mained for  several  days  in  a  state  of  unconsciousness.  On  the 
fourth  day  after  the  attack,  when  consciousness  had  fully  re- 
turned, he  complained  of  pain  and  tenderness  at  a  point 
about  three  inches  below  and  to  the  right  of  the  articulation 
of  the  lumbar  vertebra  with  the  sacrum.  Upon  examination, 
a  spot  was  found  about  two  and  a  half  inches  in  diameter,  of 
a  dark  red  color,  appearing  much  like  an  ordinary  bed  sore. 
On  the  next  day  the  spot  appeared  somewhat  larger,  of  a 
darker  color,  with  fluctuation  and  crepitation  upon  pressure. 
Dressed  with  flax-seed  poultice. 

6th  day.  Fluctuation  and  crepitation  increased,  surface 
black  and  puffed  up ;  evidently  in  a  state  of  mortification. 
Dr.  Fischer  laid  open  the  dead  mass  with  a  scalpel,  when  a 
quantity  of  fetid  gas,  with  near  a  pint  of  dark  offensive  watery 
fluid  escaped.  The  odor  was  like  that  emanating  from  morti- 
fying parts.  He  then  injected  the  cavity  with  a  solution  of 
bromine,  one  part  of  the  comp.  sol.  to  four  of  water. 

7th  day.  Removed  the  dead  mass  and  filled  the  cavity  with 
lint,  saturated  with  the  compound  solution. 

8th.  Removed  the  remaining  mass,  and,  ha^dng  obtained 
some  pure  bromine,  applied  it  by  means  of  a  mop  twice  a  day. 
When  the  whole  of  the  dead  matter 


HOSPITAL   GANGRENE,   ERYSIPELAS,   AC.  61 

enormous  cavity,  little  if  any  less  than  a  pint  bowl  in  size,  the 
whole  depth  of  the  glutei  muscles  having  sloughed  away, 
leaving  three  or  four  square  inches  of  the  ilium  and  sacrum 
exposed. 

9th.  Sloughing  seemed  arrested  over  the  greater  portion 
of  the  surface,  but  at  a  few  points  appeared  to  be  still  going 
on.     Bromine  continued. 

10th.  Sloughing  arrested,  and  granulation  appearing;  sol. 
brom.  comp.  3j.,  water  5.  iv.,  substituted  for  pure  bromine. 

11th.  Disease  seemed  entirely  arrested,  healthy  granula- 
tions appearing  abundantly.  Weak  solution  of  the  bromine 
continued. 

The  general  treatment  was  supporting.  From  this  time  for- 
ward the  case  has  improved  as  rapidly  as  could  be  desired, 
the  cavity  filling  up  finely. 

Was  this  a  case  of  hospital  gangrene,  or  of  ordinary  morti- 
fication? At  first  it  presented  all  the  features  of  ordinary 
gangrene,  but  after  the  mortified  mass  had  been  removed,  the 
surface  had  the  appearance  and  odor  of  hospital  gangrene. 
What  could  have  caused  it  ?  There  had  been  no  hospital  gan- 
grene in  the  house  for  two  months,  and  never  any  in  the  ward 
in  which  this  patient  was.  The  parts  might  have  been  bruised 
while  the  patient  was  in  a  fit.  At  any  rate,  the  diseased  ac- 
tion seemed  to  yield  promptly  to  the  application  of  the  pure 
bromine,  so  soon  as  the  dead  mass  was  removed. 

J.  A.  DOUGHERTY,  A.  A.  S.,  U.  S.  A., 
General  Hospital  No.  3,  Louisville^  Ky.,  Aug.  Gih,  18G3. 


Greenberry  Clayton,  aged  24  years,  a  private  of  company 
D,  84th  regiment  Illinois  volunteers,  was  wounded  on  the 
31st  of  December,  1863,  at  the  battle  of  Murfreesboro,  Ten- 
nessee, by  a  musket  ball  striking  the  outer  part  of  the  middle 
of  the  right  thigh,  ranging  downwards  and  inwards  poste- 
rior to  the  femur  and  principal  vessels,  and  passing  out  through 
the  adductor  muscles,  making  a  very  extensive  and  ragged 
flesh  wound.    He  was  admitted  to  Hospital  No.  8,  Louisville, 


62  A   REPORT   ON 

Kentucky,  on  tlie  25tli  of  February,  1863,  with  the  wound 
very  painful,  parts  much  swollen,  and  general  health  much  im- 
paired. The  wound  at  the  point  of  exit  of  the  ball  was  filled 
with  a  dark,  tenacious,  thick  slough,  emitting  an  intolerable 
fetor,  and  discharging  a  thin,  sanious  matter ;  a  dossil  of  lint, 
saturated  with  pure  bromine,  was  applied  directly  to  the  wound, 
the  slough  having  been  first  carefully  removed  with  the  scis- 
sors and  forceps.  The  application  was  very  painful  for  a  few 
minutes,  but  the  deep  seated  pain  previously  existing  in  the 
parts  was  much  relieved,  and  has  continued  to  subside  ever 
since,  and  at  present  is  all  gone.  On  the  next  day  another  ap- 
plication of  bromine  and  water,  equal  parts,  with  two  parts  of 
bromide  of  potassium,  was  applied  as  before,  and  suflered  to 
remain  on  the  part  fifteen  minutes,  followed  by  a  linseed  poul- 
tice. On  the  third  day  the  gangrene  was  arrested,  the  putrid 
smell  disappeared,  the  swelling  rapidly  subsiding,  and  the 
wound  secreting  white  pus.  A  dressing  of  ung.  resinee  was 
applied,  and  the  wound  is  now  rapidly  filling  up  with  healthy 
granulations.  Has  had  no  other  treatment  beyond  that  of  at- 
tention to  the  secretions  generally.  Small  doses  of  quinine, 
light  but  nourishing  diet,  with  a  little  ale  two  or  three  times 
dail}''.  In  this  case,  although  the  spread  of  the  gangrene  was 
materially  checked  by  the  first  application  of  the  bromine, 
yet  it  was  not  until  the  third  application,  its  spread  was  en- 
tirely arrested.  The  secreting  surface  was  washed  lightly  once 
a  day,  for  four  or  five  days  after  the  gangrene  ceased,  with  a 
weak  solution  of  bromine,  one  part  of  bromine  to  sixteen  of 
water,  and  the  ung.  resinjB  with  an  emollient  poultice  to  the 
parts  in  the  meantime.  The  general  health  of  the  patient 
improved  rapidly  from  the  first  application  of  the  bromine, 
and  the  relief  experienced  from  the  aching  pain  in  the  limb 
was  gratifying  in  the  extreme.  The  wound  is  granulating 
finely,  and  bids  fair  to  recover  soon,  without  any  permanent 
deformity  or  contraction  of  the  limb. 

FRANKLIN  lEISH, 
Surgeon  in  charge  Hospital  No.  8,  Surgeon  71th  Reg.  Fa.  Vols. 
March  12th,  1863. 


HOSPITAL   GANGRENE,   ERYSIPELAS,    &C.  63 

Jolin  Bleckenderfer,  a  private  in  company  C,  79tli  Penn- 
sylvania Infantry  volunteers,  was  admitted  October  1st,  1863. 
He  had  been  wounded  at  tbe  battle  of  Perryville,  and  was 
brought  from  that  place  about  ten  days  after  receiving  the 
wound.  The  ball  had  entered  about  three  inches  below  the 
knee  on  the  outer  part  of  the  leg,  and  had  made  its  exit  about 
the  same  distance  below  the  knee  on  the  inside  of  the  leg, 
making  a  wound  of  about  six  inches  in  length.  The  tissues 
involved  were  muscular,  cellular,  and  the  bones  to  a  slight  de- 
gree, as  the  ball  had  in  its  course  scaled  off  a  small  portion  of. 
the  fibula.  The  portion  of  bone  involved  was  very  small, 
and  but  a  small  piece  of  it  was  extracted,  which  was  done 
after  about  one  month,  at  which  time  it  became  thoroughly 
detached.  Cold  water  dressing  was  applied  to  the  wound,  and 
under  its  influence  the  wound  healed  very  rapidly. 

On  or  about  the  1st  of  March  the  wound,  which  was  then 
entirely  healed  over,  commenced  to  open  again,  the  sloughing 
extending  along  the  track  of  the  old  wound  and  burrowing 
among  the  sheaths  of  the  muscles.  The  discharge  was  very 
copious,  thin,  containing  lumps  of  cellular  tissue,  and  most 
horribly  fetid.  The  parts  about  the  wound  were  very  painful 
to  the  touch,  but  not  "  inflamed. "  I  applied  at  first  a  mixture 
of  creosote  as  an  injection,  hoping  that  its  known  antiseptic 
qualities  might  produce  a  favorable  change.  I  did  not,  how- 
ever, perceive  any  advantages  from  its  use ;  the  sloughing  still 
continued,  and  the  odor  of  the  secretion  as  offensive  as  before. 
I  then  resorted  to  a  solution  of  bromine,  one  part  of  the  sol. 
bromine  comp.  and  one  part  of  water.  This  gave  him  a  good 
deal  of  pain  after  being  applied,  but  it  caused  a  diminution  of 
pain  after  the  lapse  of  an  hour,  the  leg  feeling  much  easier  than 
before  the  application.  The  effect  which  it  had  in  destroy- 
ing the  fetid  smell  was  remarkable.  That  had  almost  ceased 
after  the  second  application  of  the  bromine.  By  continuing 
this  injection  the  sloughs  were  rapidly  separated,  and  the  se- 
cretions became  more  and  more  healthy  in  appearance,  the 
gangrenous  smell  entirely  destroyed,  and  by  the  assistance  of 


64  A  REPORT   ON 

a  soaked  bandage  and  compress  the  sinuses  are  rapidly  lieal- 
ing.  I  date  the  improvement  from  the  first  application  of  the 
bromine.  The  result  of  its  use  in  this,  as  in  every  case  in 
which  I  have  used  it,  is  most  gratifying. 

I  am,  very  respectfully, 

Your  obedient  servant, 

A.  H.  SPEER, 
Surgeon  1th  Pa.  Cavalry,  in  charge  of  Hospital  No.  9. 
To  M.  Goldsmith,  Surgeon  U.  S.   Vols. 


Hospital  Ko  7,  Murfreesboro,  Tenn.,  1 
April  21st,  1862.  / 
Sir:  When  you  did  me  the  honor  to  put  me  in  charge  of 
this  hospital,  you  expressed  the  wish  that  I  would  report  to 
you  the  result  of  the  treatment  of  hospital  gangrene  by  bro- 
mine. I  beg  leave,  respectfully,  to  submit  the  report  of  all 
the  prominent  and  well  marked  cases  since  the  7th  March, 
when  I  came  in  charge,  and  to  state  that  no  other  treatment 
has  been  resorted  to  in  any  case. 

All  of  these  cases  have  been  seen  in  their  progress  and  treat- 
ment, either  by  Dr.  Brinton,  Surgeon  U.  S.  Vols.,  of  Washing- 
ton, Prof.  F.  H.  Hamilton,  Medical  Inspector,  or  Prof.  A.  C. 
Post,  of  New  York,  or  Gunn,  of  Michigan  University.  Other 
cases  than  these  now  reported  have  been  treated,  but  they 
were  slight,  or  the  gangrene  not  well  marked.  It  is  with  great 
pleasure.  Sir,  that  I  am  able,  on  the  eve  of  leaving  the  hospi- 
tal for  the  field,  to  report  that  not  a  death  has  occurred  in  the 
gangrene  ward,  and  no  case  has  been  treated  unsuccessfully. 
I  have  the  honor  to  be. 

Sir,  your  obedient  servant, 

BEITJ'N  WOODWARD, 
Surgeon  22d  Illinois  Volunteers. 
To  G.  Perin,  Surgeon  U.  S.  A., 

3Iedical  Director  Department  of  the  Cumberland. 


HOSPITAL    GANGRENE,    ERYSIPELAS,    AC.  65 

Rejjort  of  cases  of  Hospital  Gangrene,  treated  with  bromine,  in 
General  Hospital  JVo.  7,  3Iurfrcesboro,  Tenn.,  from  3Iarch  7ih  to 
April  27th,  1863,  bi/  B.  Woodward,  Surgeon  in  charge: 

Condor,  John,  company  K,  40tli  Illinois,  was  in  tlie  hos- 
pital March  7th;  right  leg  had  been  amputated,  and  gangrene 
supervened.  The  stump  was  open,  and  the  flaps  had  nearly  all 
sloughed  away,  leaving  exposed  the  tibia,  which  exfoliated. 
The  sloughing  was  arrested  by  bromine,  and  the  stump  dressed 
as  well  as  it  could  be.  The  stump  is  now  nearly  healed,  only 
a  small  spot  remaining  not  cicatrized. 

Hall,  H.  B.,  company  C,  13th  Michigan,  in  hospital 
March  7th:  gangrene  from  wound  of  leg;  slough  was  five  and 
a  half  inches  long,  two  and  a  half  wide,  and  down  to  the  tibia, 
the  periosteum  of  which  was  destroyed,  and  exfoliation  took 
place.     This  case  is  now  nearly  well. 

Bowman,  James,  company  G,  1st  East  Tennessee  regi- 
ment, in  hospital  March  7th :  gun  shot  through  left  leg,  tibia 
slightly  injured,  and  gangrene  filled  the  wound,  which  on 
the  outside  of  the  leg  was  four  inches  by  three,  inside  five 
inches  by  two  and  a  half,  and  extending  through  the  track 
of  the  ball ;  now  nearly  well,  only  a  small  place  on  the  inside 
of  leg  not  yet  cicatrized. 

McCreary,  Jesse,  1st  East  Tennessee,  corporal,  company  C, 
in  ward  March  7th :  had  gangrene  of  knee  from  gun  shot ;  had' 
March  7th  a  large  bed  sore  over  the  sacrum  four  inches  in  di- 
ameter, and  to  the  bone,  which  had  sloughed  by  gangrene  and 
was  spreading;  now  nearly  healed  up. 

Bader,  John,  company  G,  32d  Indiana,  sent  from  Hospital 
K"o.  1,  ]March  8th,  with  extensive  gangrene  of  right  thigh,  from 
gun  shot  wound,  ball  passing  through  upper  third  of  thigh. 
On  the  outside,  the  wound  was  five  inches  in  diameter,  and 
destroyed  the  tensor  vaginfe  femoris  and  part  of  vastus  cxter- 
nus;  on  the  inside,  the  wound  was  three  inches  in  diameter, 
and  over  the  femoral  artery,  which  was  exposed  two  and  a  half 
inches  below  Poupart's  ligament.  The  whole  of  both  wounds 
are  now  full  level  with  the  surface,  with  healthy  granulations,. 
and  nearly  healed  over. 


QQ  A   REPORT   ON 

Boyer,  "William,  company  B,  49tli  Ohio,  sent  from  Hospital 
No.  1,  March  12th,  with  extensive  gangrene  of  left  thigh,  from 
a  ball  passing  through.  The  slough  on  the  outside  of  the 
thigh  was  six  inches  long  by  four  inches  wide,  and  in  some  parts 
one  and  a  half  inches  deep.  The  semi-tendiuosus  and  great  part 
of  the  vastus  externus  had  sloughed  away,  and  a  sinus  ran 
down  on  the  outside  of  the  knee.  Every  part  was  subjected  to 
the  action  of  bromine,  and  the  sinus  injected  in  its  whole  length. 
When  he  was  admitted  his  death  was  considered  certain,  but 
the  progress  of  the  disease  was  arrested,  and  now  the  wound 
is  only  three  and  a  half  inches  long  by  one  inch  wide,  and  filled 
nearly  to  the  surface  with  healthy  granulations. 

Miller,  John  B.,  company  B,  101st  Indiana,  sent  from  Hos- 
pital K'o.  1,  April  1st,  with  gangrene  of  thigh  from  gun  shot. 
This  case  was  seen  by  Professor  F.  H.  Hamilton,  when  first 
brought  in  and  before  it  had  been  dressed.  So  extensive  was 
the  gangrene  that  little  hopes  of  his  recovery  remained.  The 
sore  is  now  only  about  three  inches  over,  and  rapidly  filling  up 
with  healthy  granulations. 

Webber,  Herft-y,  company  F,  7th  Pennsylvania  Cavalry,  sent 
from  Hospital  No.  1,  April  1st,  with  gangrene  of  the  foot,  from 
gun  shot  through  part  of  foot ;  one  toe  had  been  amputated. 
This  case  was  also  seen  by  Professor  Hamilton ;  now  nearly 
healed. 

Biggie,  Michael,  company  G,  101st  Indiana,  sent  from  Hos- 
pital No.  1,  April  12th,  with  gangrene  of  the  stump  after  am- 
putation of  leg.  Flaps  had  nearly  all  sloughed  away,  and  the 
tibia  bared.  This  case  is  now  rapidly  healing  from  granula- 
tion, but  his  health  is  very  bad  from  remittent  fever,  and  his 
recovery  is  doubtful. 

Clark,  Kobert,  company  G,  101st  Indiana,  sent  from  Hospi- 
tal No.  1,  April  12th :  gun  shot  wound  through  left  leg,  tibia 
badly  shattered,  both  wounds  of  entrance  and  exit,  and  track 
of  ball,  a  mass  of  gangrene.  Both  this  case  and  the  one  fol- 
lowing were  watched  by  Professors  Post,  of  New  York,  and 
Gunn,  of  Michigan  University,  for  two  days,  and  the  action 
of  the  bromine  marked.     The  destruction  of  parts  was  prompt- 


HOSPITAL   GANGRENE,   ERYSIPELAS,    AC.  07 

\y  arrested,  and  now  the  whole  Avound  is  rapidly  filling  up  with 
healthy  granulations. 

Wilson,  L.  D.,  lieutenant,  company  G,  101st  Indiana,  sent 
from  Hospital  ISTo.  1,  April  12th,  with  extensive  gangrene  of 
thigh  from  gun  shot  wound.  The  slough  was  very  extensive 
and  deep,  and  the  Avhole  was  in  very  bad  condition.  It  is  now 
rapidly  healing  and  his  general  health  improving. 

In  all  cases  of  extensive  gangrene,  there  is  remarkable  de- 
pression; and  not  the  least  gratifying  feature  of  the  bromine 
treatment,  especisiWj  where  its  coiistitutional,  as  well  as  local  use 
is  carried  out,  is  the  rapid  general  improvement  of  the  health. 
The  countenance  loses  its  anxious  expression,  and  the  leaden, 
sallow  hue  is  replaced  by  a  healthy,  vigorous  color,  and  the 
appetite  is  always  improved. 

Very  respectfullj', 

.  B.  WOODAVARD, 

Surgeon  in  charge. 


Louisville,  Kt.,  May  18th,  1863. 

Philip  Dill,  private,  company  D,  13th  Louisiana  Infantry, 
aged  35  years,  and  of  good  constitution,  was  wounded  at  the 
battle  of  Stone  River,  on  the  2d  of  Januarj-,  1863,  by  a  rifle  or 
musket  ball,  which  passed  through  the  left  thigh,  fracturing 
the  femur  near  the  junction  of  the  upper  and  middle  third. 
There  was  little  laceration  of  soft  parts,  and  the  vessels  were 
uninjured;  the  leg  was  amputated  January  3d,  1863,  at  hos- 
pital in  rear  of  Murfreesboro,  by  Surgeon  Rief,  of  21st  Wis- 
consin, at  a  point  immediately  above  the  injury.  The  soldier 
did  very  well  afterwards,  and  had  a  good  stump,  which  was 
entirely  healed  on  March  26th,  1863,  at  which  time  he  was 
transferred  to  this  city.  The  wound  assumed  a  gangrenous 
character,  to  some  extent,  about  the  18th  of  April. 

On  the  20th  the  cicatrix  had  given  away,  the  flaps  gangre- 
nous, looking  dark  and  flabby.  The  fetor  was  very  great; 
pulse  120  and  feeble;  tongue  dry;  cadaverous  expression  of 


68  A   REPORT    OX 

the  countenance,  dusky  liue  of  the  face,  no  appetite,  shigultus, 
profuse  colliquative  sweats,  and  extreme  muscular  prostration, 

April  22d.  The  sloughs  were  cleanly  removed  with  a  knife, 
the  parts  dried,  and  pure  bromine  applied  to  the  surface  as 
directed  by  Surgeon  M.  Goldsmith,  and  stimulants,  tonics,  and 
nutritious  diet  given  internally. 

April  23d.  Pulse  100  and  stronger;  sweats  disappeared; 
no  singultus ;  patient  expressed  himself  as  feeling  much  bet- 
ter ;  some  fetor  present  in  the  wound,  and  two  points  were  re- 
touched with  bromine,  after  which  all  fetor  disappeared,  and 
has  not  returned  up  to  this  date,  May  18th,  18G3.  Granula- 
tions began  to  make  their  appearance  April  18th,  four  days 
after  the  bromine  was  applied,  when  the  gangrene  was  arrest- 
ed and  the  sloughs  entirely  separated.  The  bone  protruded 
about  one  inch,  and  is  now  necrosed. 

For  several  days,  about  this  time,  the  patient  improved  rather 
slowly,  the  granulations  seeming  weak  and  flabby.  I  attribut- 
ed this  condition  to  bad  ventilation,  and  advised  that  he  be 
removed  to  Hospital  No.  1,  w^here  he  could  have  better  air, 
which  was  done,  and  he  improved  much  more  rapidly. 

lie  was  much  emaciated,  and  had  decubitus;  a  large  bed 
sore  was  found  over  the  sacrum,  about  three  inches  in  diame- 
ter, which  became  gangrenous  May  2d.  The  dead  mass  was 
removed,  parts  dried,  and  pure  bromine  applied  to  the  surface. 
The  first  application  arrested  the  process,  and  the  sore  is  now 
nearly  filled  up  with  healthy  granulations. 

A  fact  will  be  noted  here  that  this  wound  became  gangren- 
ous at  the  same  time  that  the  stump  was  granulating,  and  not 
afiected  in  the  least  by  the  upper  sore.  It  will  also  be  noticed, 
as  was  observed  and  commented  upon  by  Drs.  Barnum  and 
Gregg,  who  had  the  care  of  the  case,  how  rapidly  the  consti- 
tutional symptoms  gave  way  to  the  effect  of  the  local  remedy. 
After  he  was  removed  to  Hospital  Is'o.  1,  he  was  put  in  the 
upper  ward,  and  near  a  large  window,  when  his  improvement 
seemed  to  receive  a  new  impetus;  since  then  he  has  recov- 
ered very  rapidly,  and  at  this  time,  May  18tli,  he  has  a  good 


HOSPITAL    GANGRENE,   EnYSirELAS,    &C.  G9 

appetite,  pulse  85,  tongue  clean  and  moist,  countenance  bright, 
wounds  full  of  granulations,  having  the  appearance  of  healthy 
sores. 

G.  R.  WEEKS,  Surgeon  U.  S.   Vols. 
To  M.  Goldsmith,  Surgeon  U.  8.  Vols. 


Louisville,  Kt.,  May  18th,  1863. 

Jefierson  Terrell,  private  company  K,  17th  Tennessee  In- 
fantry, C.  S.  A.,  aged  20,  of  good  constitution  -and  temperate 
habits,  was  wounded  in  battle  of  Stone  River,  December  31st, 
1862,  in  the  calf  of  right  leg,  carrying  away  both  the  tibia  and 
fibula;  leg  was  amputated  at  the  junction  of  the  upper  and 
middle  third,  at  hospital  in  Murfreesboro,  by  a  Confederate 
eurgeon,  January  1st,  1863.  He  had  a  good  recovery,  and 
he  states  that  his  stump  was  entirely  healed.  He  received  a 
fall,  March  13th,  by  the  breaking  of  his  crutch,  falling  on  the 
end  of  his  still  tender  stump.  On  this  day  he  was  removed 
from  Murfreesboro  to  Hospital  No.  2,  in  this  city.  According 
to  his  statement,  the  stump  became  gangrenous  the  next  day 
after  his  arrival,  March  13th.  He  was  treated  from  that  time 
until  16th  April  by  Surgeon  Ronald,  34th  Ky.  Volunteer  In- 
fantry, in  charge  Hospital  No.  2.  Surgeon  Ronald  being  re- 
lieved at  this  time,  has  since  been  absent,  and,  as  no  record  of 
the  case  was  kept  by  him,  it  is  impossible  to  know  how  the 
case  was  treated. 

On  the  16th  of  April  the  soldier  was  attacked  by  profuse 
hemorrhage  from  the  stump,  the  anterior  tibial  artery  having 
sloughed.  At  this  date  the  patient  was  seen  by  Surgeon  Gold- 
smith, U.  S.  Vols.,  who  directed  me  to  tie  the  artery  on  the 
face  of  the  slough,  and  to  take  charge  of  the  case.  I  found 
him  cold  and  pulseless  from  loss  of  blood;  he  had  bled  about 
fifty  ounces,  but  the  bleeding  had  been  arrested  previous  to 
my  arrival  by  the  application  of  a  tourniquet  to  the  femoral 
artery.  I  ordered  him  to  have  stimulants,  and  waited  a  short 
time  until  reaction  should  take  place.  Upon  the  removal  of 
fieveral  adliesive  plasters  that  crossed  the  face  of  the  stump,  I 


70  A   REPORT    ON 

found  a  large  gangrenous  mass,  tlie  parts  looking  very  dark, 
and  emitting  a  very  offensive  odor ;  I  removed,  with  the  seal- 
pel  and  scissors,  a  double  hand-full  of  putrid  sloughs,  partly 
fluid,  partly  pulpous,  partly  solid,  and  in  all  stages  of  j>utre- 
factive  decomposition.  After  having  done  this,  the  tibia  and 
flbula  projected  two  inches,  but  were  not  denuded  of  perios- 
teum, nor  were  they  necrotic.  I  prepared  the  wound  as  de- 
scribed in  accompanying  report  on  hospital  gangrene,  and 
applied  pure  bromine;  I  also  injected  the  latter  into  the  spaces 
and  cavities,  using  the  precaution  to  mix  it  with  all  the  pulp 
or  pultaceous  fluid.  I  then  loosened  the  tourniquet,  and  no 
hemorrhage  re-appearing,  I  determined  to  follow  Guthrie — 
"never  to  tie  an  artery  unless  it  bleeds."  I  gave  the  necessa- 
ry directions  to  avoid  loss  of  blood  in  case  the  hemorrhage 
should  recur,  and  started  back  to  the  office,  but  was  soon 
overtaken  by  a  messenger  who  informed  me  that  the  man  was 
bleeding  again,  and  that  the  surgeon  in  charge  wished  me  to 
return.  He  had  lost  one  or  two  ounces  only,  I  then  tied  the 
anterior  tibial  artery  as  directed,  and  again  applied  bromine  to 
the  entire  surface  of  the  wound,  also  to  the  portion  of  the  ar- 
tery included  within  the  ligature.  My  reason  for  so  doing  was^ 
that  I  thought  the  blood  might  have  washed  the  bromine  first 
applied  from  the  surface,  a  reason  which  I  now  think  was  in- 
suflicient.  I  ordered  a  trusty  attendant  to  be  kept  at  the  bed- 
side day  and  night,  instructed  in  the  use  of  the  tourniquet, 
which  was  loosely  applied. 

April  17th.  Pulse  100,  heat  of  surface  about  natural; 
tongue  moist;  no  saccharine  odor  of  the  breath;  appetite 
returning;  no  fetor  in  the  wound;  leaden  hue  of  the  fiice  dis- 
appeared, rested  well  during  the  night.  Ordered  egg-nog, 
iron,  also  nutritious  diet,  and  that  the  wound  be  kept  from 
the  atmosphere. 

April  18th.  Pulse  100,  strong,  and  full;  symptoms  every- 
way better ;  treatment  continued. 

April  19tli.     Pulse  95;  warm  water  dressings  to  the  wound. 

April  20th.  Still  improving,  points  of  granulation  spring- 
ing up  ;  looks  pale ;  no  fetor ;  applied  bromine  one  part,  water 


HOSPITAL   GANGRENE,   ERYSIPELAS,    AC,  71 

twelve  parts,  twice  a  day.  Stimulants  coiitiuued,  decreased  iu 
quantity.  This  evening  ligature  came  away  ;  no  hemorrhage 
from  the  wound  ;  granulations  more  ahundant  but  still  feeble. 

April  21st.  Pulse  90,  full  and  soft ;  patient  has  rallied  very 
much;  pus  discharged  is  inodorous,  but  is  thin  and  abounds  in 
jnolecular  matter  rather  than  pus  globules. 

April  22d.  Had  been  removed  to  Hospital  No.  1,  which  is 
better  ventilated,  from  which  he  received  much  benefit,  and 
from  that  time  he  has  steadily  and  rapidly  improved  up  to  the 
present. 

May  18th.  The  tibia  and  fibula  are  both  covered  with 
healthy  granulations,  the  wound  is  filling  up,  and  his  health  is 
sufiicient  to  enable  him  to  sit  up  the  greater  part  of  the  day. 
He  is  now  fully  convalescent. 

G.  R.  WEEKS,  Surgeon  U.  S.  Vols. 

To  M.  Goldsmith,  Surgeon  U.  S.   Vols. 


United  States  General  Hospital,  Xo.  1,         \ 
Louisville,  Kentuckj^,      j 
A.  C.  T.  WoRTHiNGTON,  A.  A.  Surgcou  in  charge : 

William  Turner,  private,  company  E,  8th  Kentucky  Volun- 
teers, (a  discharged  soldier,)  was  wounded  at  the  Soldier's 
Home,  by  an  accidental  discharge  of  a  pistol  in  the  hands  of  a 
comrade,  on  the  7th  of  March.  The  ball  entered  the  anterior 
and  middle  portion  of  the  right  leg,  passing  down  the  tibia 
about  two  inches,  where  it  was  found  and  extracted  on  the 
10th  of  March.  Three  days  after  he  w^as  admitted  into  this 
hospital,  he  was  attacked  with  inflammation  of  the  right  lung 
(his  constitution  being  much  sha^ered  by  previous  disease), 
which  raged  for  about  ten  days.  Notwithstanding  the  sup- 
porting treatment,  which  was  strictly  observed,  he  sank  into  a 
hectic  condition.  The  harrassing  cough,  drenching  sweats, 
and  the  sloughing  of  the  wound,  rendered  his  case  almost 
hopeless.  Quinine,  iron,  whisky,  ale,  boiled  eggs,  and  beef 
tea,  were  freely  administered,  and  stimulating   applications 


72  A   EEPORT    ON 

were  made  to  the  part  without  effect.  On  the  1st  of  April 
the  sloughing  had  extended  to  about  four  inches  in  length  and 
three  in  breadth.  The  soft  parts  were  converted  into  a  green- 
ish grey,  pulpy,  tenacious  mass ;  the  tibia  was  denuded ;  there 
was  considerable  burning  and  lancinating  pain  in  the  parts,  with 
considerable  fetor.  The  same  treatment  was  continued,  with 
the  same  result,  up  to  the  11th  of  April,  at  which  time  the 
sloughs  were  cut  away,  the  wound  thoroughly  cleansed,  and 
the  solution  of  bromine  was  injected.  Lint,  saturated  with  the 
solution,  was  placed  in  the  wound.  The  limb  was  enveloped 
in  a  piece  of  lint,  wrung  out  of  tepid  water,  and  covered  with 
oiled  silk. 

On  the  morning  of  the  12th  the  dressing  was  removed. 
The  character  of  the  wound  was  changed  from  a  greyish  or 
blackish  stinking  mass  to  a  red,  healthy  looking  ulcer,  with 
little  or  no  fetor.  A  weak  solution  was  again  injected,  and 
the  lint  applied  as  before. 

On  the  13th  the  ulcer  still  improving;  bromine  applied  to  a 
few  parts. 

14th.  Granulations  springing  up  all  over  the  surface  of  the 
ulcer;  general  condition  better;  appetite  much  improved; 
warm  water  dressings. 

,  15th.  Two  small  pieces  of  bone  removed ;  patient  entirely 
free  from  pain  and  cough  ;  continue  dressings. 

17tli.  Still  improving,  able  to  sit  up  in  bed;  appetite  re- 
markably good. 

20th.  Steadily  improving  since  the  first  application  of  the 
bromine,  which  arrested  the  gangrene  immediately.  The  pa- 
tient reports  himself  in  better  health  than  at  any  time  since 
his  discharge.  In  this  case  the  other  usual  remedies  had  a 
.-sufficient  trial  before  bromine  was  used. 


[The  following  case  has  more  relation  to  the  production 
of  pyemia  than  to  the  treatment  of  hospital  gangrene.] 

Frederick  Jones,  private,  co.  II.  5th.  Ivy.  Infantry,  act.  22. 


HOSPITAL   GANGRENE,   ERYSIPELAS,   &C.  73 

111  tliG  battle  of  Stone  River,  Dec.  31st,  1862,  he  received  a 
gunshot  wound  in  the  left  leg — the  ball  entered  on  the  exter- 
nal side  of  the  leg,  about  six  inches  below  the  patella,  and, 
passing  inwards  and  backwards,  made  its  exit  on  the  internal 
and  posterior  surface  of  the  leg.  According  to  the  patient's 
statement,  the  case  progressed  favorably,  until,  whilst  on  his 
way  to  Louisville,  erysipelas  set  in. 

The  disease  yielded  to  treatment,  and,  as  far  as  the  erysipe- 
las was  concerned,  the  patient  was  well  at  the  time  of  his  ad- 
mission into  this  hospital. 

Present  Condition. — Admitted  on  the  18th  of  January,  1863. 
I  find  his  condition  to  be  as  follows :  He  is  pale  and  some- 
what reduced  in  strength ;  his  intellect  is  clear,  but  he  is  very 
nervous,  and  the  least  excitement,  or  even  muscular  exertion, 
brings  on  a  violent  fit  of  trembling ;  pulse  104.  The  left  ex- 
tremity is  swollen  and  red,  and  the  rednftss  and  swelling  ex- 
tend above  the  knee  ;  the  wound  looks  inflamed,  the  edges 
are  tumid  and  everted,  and  almost  perfectly  dry.  Both  open- 
ings are  small,  and,  on  inserting  fhe  probe,  I  find  the  fibula 
has  been  fractured.  I  could  feel  a  small  piece  of  bone,  but  as 
the  patient  was  very  irritable,  I  determined  to  abstain  from 
interfering  until  the  inflammation  should  subside. 

Treatment. — Cold  water  dressings  were  applied  to  the  limb, 
and  thfe  following  prescription  exhibited  :  Spts.  eth.,  comp. 
ext.  valerian,  aa.  3j.,  to  be  taken  every  three  hours,  and  the  pa- 
tient was  kept  on  low  diet.  This  treatment  was  continued 
until  January  25th,  when  the  inflammation  was,  to  a  great  ex- 
tent, subdued.  The  cold  water  dressings  were  still  continued, 
and  he  was  allowed  an  ounce  of  Sherry  wine  three  times  a 
a  day,  though  still  kept  on  low  diet.  The  wound  had  in  the 
meantime  commenced  to  suppurate  freely,  and  the  pus  ap- 
peared to  be  of  good  quality. 

January  27.  Patient  continues  to.  improve  ;  he  sleeps  well, 
but  his  appetite  is  still  poor.  He  was  ordered  to  take  wine, 
3j.,  with  sol.  of  quin.,  3ij.,  three  times  a  day.  He  was  also  put 
on  half  diet. 


74  A   REPORT   ON 

February  1st.  Patient  improving,  but  tlie  wound  sliows 
no  disposition  to  heal.  Midway  between  the  patella  and 
malleolus,  and  immediately  external  to  the  crest  of  the  tibia, 
a  small  abscess  is  to  be  seen.  On  laying  it  open,  it  is  found  to 
communicate  with  the  wound,  which  secreted  thinner  and  less 
healthy  looking  matter ;  the  odor  is  becoming  offensive  ;  the 
cold  water  applications  are  still  continued,  as  the  temperature 
of  the  limb  immediately  rises  on  their  being  discontinued, 
which  also  causes  the  parts  to  become  red  and  painful.  Pre- 
scription :  Sol.  quin.  3ij.,  spts.  frumenti  3ss.,  three  times  a  day, 
with  half  diet. 

February  8th.  During  the  last  week  he  has  continued  to 
take  whisky  and  quinine  in  doses  as  above,  with  the  addition 
of  tinct.  ferri  chloridi,  gtt.  xx.,  but  there  has  been  no  marked 
improvement.  During  the  night  he  had  a  violent  chill,  and 
when  seen  this  morning  his  pulse  was  100,  feeble  and  irregu- 
lar ;  he  has  lost  all  desire  for  food,  and  on  the  left  foot  is  a  fluc- 
tuating swelling,  situated  immediately  over  the  external  cu- 
neiform bone.  I  laid  it  open,  and  found  that  a  sinus  extended 
up  along  the  leg,  behind  the  external  malleolus.  Another 
swelling  was  found  immediately  behind  the  internal  malleo- 
lus, and  extending  upward  in  the  track  of  the  flexor  longus 
poUicis ;  this  was  also  laid  open,  and  both  abscesses  discharged 
thin  fetid  matter.  The  foot  had  also  commenced  t©  swell. 
The  original  wound  had  commenced  discharging  matter  like 
that  in  the  abscesses,  and  on  probing  it  to  find  fragments  of 
bone,  I  discovered  that  there  was  a  large  cavity  in  the  thick- 
ness of  the  gastrocnemius  muscle.  I  dilated  the  opening,  and 
found  the  walls  lined  with  a  thick  slough ;  I  could  touch  frag- 
ments of  bone  with  a  probe,  but  never  succeeded  in  laying 
hold  of  one  with  the  forceps.  Quinine,  iron,  and  alcoholic 
stimulants  were  freely  administered  in  doses  as  stated,  and 
creasote  3j.,  alcohol  3ss..  water  3j.  ss.,  sprinkled  on  poultices 
applied  to  the  parts ;  anodynes  were  given  every  night,  and 
without  them  he  could  not  sleep.  The  following  prescription 
was  used :  Sol.  morph.  3j.  and  spts.  eth.  comp.  3ij.  every  night 
at  bed-time. 


HOSPITAL   GANGRENE,    ERYSIPELAS,    AC.  75 

Feb.  15th.  The  patient  is  decidedly  worse  than  hist  weelv ; 
he  has  repeated  chills,  copious  night  sweats,  a  loathing  of 
food,  especially  meat  of  any  kind.  Creasote  seems  to  neu- 
tralize the  fetor,  hut  the  sloughs,  especially  on  the  foot,  arc  as 
thick  and  adhere  as  firmly  as  before.  During  the  first  two 
days,  after  the  application  of  creasote,  I  think  there  was  some 
improvement  in  the  appearance  of  the  gangrenous  surface,  and 
observed  a  corresponding  improvement  in  the  constitutional 
symptoms ;  but  he  is  now  in^  as  bad  condition  as  ever.  Same 
treatment  continued  as  before,  with  the  addition  of  elixir  of 
vitriol  in  doses  of  xx.  gtt.,  four  times  a  day. 

Feb.  20th.  Patient  continues  in  same  condition;  his  pulse 
is  112  and  irregular;  chills  and  night  sweats  as  before.  He 
takes  wine  3j.  three  times  a  day,  in  addition  to  the  prescrip- 
tions before  mentioned,  and  oysters  and  beef  tea.  The  fetor 
of  the  discharges  is  almost  intolerable,  and  the  stools  emit  a 
similar  odor,  and  are  very  thin  and  frequent.  I  enlarged  the 
original  wound,  and  laid  the  sinuses  on  the  anterior  surface 
of  the  leg  and  on  the  foot  freely  open,  and  injected  a  strong 
solution  of  bromine.  This  gave  the  patient  severe  pain,  but 
changed  the  character  of  the  discharges  almost  immediately. 

The  efiTects  of  the  application  of  bromine  may  be  more 
clearly  demonstrated  by  passing  over  a  few  days,  and  con- 
trasting his  condition  then  to  what  it  was  previous  to  the  use 
of  this  remedy. 

Feb.  28th,  He  says  he  feels  better;  he  slept  well  during  the 
night ;  has  had  no  chill  for  several  days ;  night  sweats  are  not 
80  copious,  nor  do  they  occur  every  night.  His  pulse  is  98,. 
and  regular ;  his  appetite  is  returning,  but  he  still  has  a  dis- 
like of  meats. 

Treatment  continued  as  before,  and  a  weaker  solution  of 
bromine  injected  every  twenty-four  hours.  The  fetor  has  not 
returned  ;  sloughs  are  becoming  loose,  and  the  discharges  have 
become  thicker,  and  of  a  healthy  color.  The  opening  of  en- 
trance is  healing  rapidly,  and  this  morning  I  extracted  two 
small  pieces  of  bone  through  the  hole  of  exit. 

March  1st.    Patient  continues  to  improve.     Wherever  the 


76  A   REPORT    ON 

sloughs  have  come  off,  I  can  discern  health}^  granuhations. 
On  probing  the  wound,  I  felt  a  piece  of  bone  which  was  ex- 
tracted, and  measured  one  inch  and  a  half  by  one  half  inch. 

March  3th.  Patient  still  improving,  but  very  weak.  Sores 
have  assumed  a  healthy  appearance.  Quinine,  iron,  and  ale, 
with  a  generous  diet,  have  been  prescribed.  Bromine  discon- 
tinued. 

March  6th.  Patient  feels  worse ;  fetor  has  returned;  dis- 
charges have  become  thinner  and  of  a  darker  color. 

March  7th.  He  continues  getting  worse.  During  yester- 
day afternoon  he  was  seized  with  rigors,  recurring  during  the 
night,  and  followed  by  profuse  sweats,  which  have  left  him 
quite  exhausted.  Poultices  were  applied,  and  continued  until 
the  13th  of  March,  when  the  sore  on  his  left  foot  was  again 
covered  with  thick  sloughs  of  a  dark  leaden  color,  and  dis- 
charging thin  sanious  matter,  emitting  a  most  intolerable 
stench.  I  trimmed  off  the  sloughs  with  scissors,  and  injected 
the  compound  solution  of  bromine.  This  I  repeated  twice  daily, 
re-applying  the  poultice  after  each  injection.  Tonics  and 
stimulants  were  freely  administered. 

The  bromine  arrested  the  spreading  of  the  gangrene  imme- 
diately, and  neutralized  the  stench.  On  the  18th  of  March 
all  sloughs  had  come  away,  and  there  was  now  a  healthy  gran- 
ulating ulcer ;  the  swelling,  which  had  been  very  great,  had 
entirely  subsided.  I  applied  unguentum  resinte,  and  contin- 
ued to  give  quinine  and  alcoholic  stimulants.  It  must  be  re- 
marked that  the  constitutional  symptoms  underwent  a  marked 
improvement  whenever  the  gangrenous  surface  was  fully 
brought  under  the  influence  of  bromine  ;  in  other  words,  the 
symptoms  of  pyaemia  disappeared  almost  simultaneously  Avith 
the  arrest  of  the  fetid  discharges,  and  re-appeared  with  the 
return  of  the  latter. 

April  2d.  The  patient  is  improving  rapidly ;  the  ulcer  on 
the  foot  and  leg  have  entirely  healed,  but  the  hole  of  exit  in 
the  calf  still  remains  open.  I  extracted  another  piece  of  bone 
this  morning  one  inch  by  one-quarter,  and  hope,  this  source  of 


HOSPITAL    GANGRENE,    ERYSIPELAS,    &€.  77 

irritation  being  removed,  tlic  ulcer  will  speedily  follow  the  ex- 
ample of  tlie  otlier  cases.     Respectfully  submitted, 

JOHN"  A.  OCTERLONY,  A.  A.  S.  U.  6.  A., 

General  Hospital  No.  8,  Louisville,  Ky. 


IIospiTAL  Ko.  4,  Kashville,  Tenn.,  I 
July  22d,  1863.      / 

Sir  :  I  have  the  honor  to  report  that,  in  compliance  with 
your  order,  I  have  visited  the  various  hospitals  in  this  city  and 
recorded,  on  the  accompanying  blanks,  all  the  cases  of  hospital 
gangrene,  not  before  reported,  that  have  occurred  therein. 

It  will  be  observed  that  of  the  thirty-five  cases  noted,  nine 
proved  fatal.  This  mortality  may  not  be  attributed,  per- 
haps in  any  degree,  to  the  method  of  treatment  employed;  for 
in  some  of  the&e  cases  the  primary  injury  was  of  a  serious  na- 
ture, and  the  operations  performed  might  have  provoked  a 
fatal  result,  even  if  gangrene  had  not  existed  prior  to  the  ope- 
ration, or  attacked  the  stump  at  a  subsequent  period ;  but  it  is 
a  remarkable  fact,  that  in  none  af  the  fatal  cases  was  bromine 
used,  except  in  one,  and  in  this  case  the  bromine  was  applied 
only  a  few  hours  before  the  patient  s  death. 

Of  the  nineteen  cases ,  treated  with  bromine,  either  from 
the  commencement  or  during  the  progress  of  the  disease,  all 
recovered.  The  remaining  seven  cases  that  recovered  were 
treated  with  nitric  acid,  antiseptic  washes,  poultices,  etc.  The 
general  treatment  was  similar  in  all  the  cases;  being  of  a  sup- 
porting and  tonic  character.  ^        -^         ^^        >'^        -^ 

Average  duration  of  the  gangrene  in  those  cases  treated  with 
bromine — 3  days  and  3  hours ;  average  duration  of  the  gan- 
grene in,  those  cases  treated  without  bromine  that  recovered — 
5  days  and  11  hours. 

Very  respectfully,  your  obt.  servt., 

C.  II.  BILL,  A.  A.  Surg.  IT.  S.  A. 
To  A.  Henry  Thurston,  Surg.  IT.  S.  Y., 

Assist.  Med.  Dir.  Dept.  of  the  Cumberland. 


78  A   REPORT    ON 

In  conclusion,  I  have  to  append  a  consolidated  statement  of 
the  cases  of  hospital  gangrene  reported  to  me  as  treated  at 
Louisville,  Kentucky ;  New  Albany,  Indiana ;  ISTashville,  Ten- 
nessee, and  Murfreesboro,  Tennessee.  Many  more  cases  have 
occurred  in  these  several  places,  but  I  have  been  unable  to 
procure  such  records  as  would  make  them  suitable  bases  of 
tabular  statements. 

I  have  carefully  excluded  all  cases  of  which  I  am  not  as- 
sured, by  personal  inspection  or  the  written  record,  were 
cases  of  genuine,  unmistakable  hospital  gangrene.  The  full 
records  of  the  cases  are  reported  in  the  roll  sent  to  the  Sur- 
geon General's  office,  and  in  the  table  hereto  appended. 

It  will  be  seen  that  among  the  deaths  are  four  reported  as 
■occurring  amongst  those  treated  with  bromine.  In  two  of 
these  the  wounds  traversed  thick  fleshy  parts,  and,  for  reasons 
obvious  in  the  record,  the  bromine  was  never  applied  to  the 
whole  gangrenous  surfaces  or  even  the  major  part  of  them.  In 
another,  the  gangrenous  affection  was  complicated  witli  acute 
gangrenous  cellulitis  (?),  extending  from  the  trochanter  to  the 
malleoli,  the  whole  cellular  membrane  underlying  the  skin 
having  been  destroyed.  In  another  the  bromine  was  not  ap- 
plied until  the  day  before  death,  the  man  being  almost  mori- 
bund on  admission. 

Three  died  of  pyemic  affections  after  the  arrest  of  the  gan- 
grene, and  the  development  of  granulation  throughout  the 
extent  of  the  wounds. 

It  will  be  seen,  also,  that  four  cases  are  reported  in  which 
the  bromine  is  said  to  have  fixiled  in  arresting  the  disease. 

I«  one  of  these  the  bromine  had  been  applied  every  four 
hours  for  several  days,  and,  granulations  not  appearing,  the  sur- 
geon applied  a  weak  solution  of  creasote,  and  this  was  follow- 
ed quickly  by  the  appearance  of  granulations.  In  two  other 
cases,  after  the  assiduous  application  of  strong  bromine,  a  solu- 
tion of  the  persulphate  of  iron  was  used,  and  the  granulations 
sprang  up  at  once.  In  another,  the  surgeon  reports  that  he 
used  the  strong  applications  twice  a  day  for  twenty-eight  days, 


HOSPITAL   GANGRENE,   ERYSIPELAS,   l-C.  79 

and  he,  tooy  becoming  discouraged,  resorted  to  tlie  use  of  a 
cow-dung  poultice,  and  straightway,  as  in  the  other  cases,  the 
disease  was  arrested  and  granulation  began.  In  all  of  these 
cases  I  tliink  it  possible  that  there  may  have  been  a  too  free 
and  frequent  use  of  the  bromine.  It  would  be  difficult  for  the 
cleanest  cut  surface  to  granulate  with  even  one  application  of 
the  compound  solution  per  day,  if  it  was  applied  in  a  way  cal- 
culated to  arrest  the  gangrenous  process. 

[  As  these  pages  are  going  through  the  press,  a  friend  suggests  that  the  note  on 
page  32  may  convey  an  impression,  neither  justified  by  the  facts,  nor  intended  to 
be  made  by  what  is  written.  The  wounded  referred  to  had,  all  of  them,  those 
slight  injuries  which  needed  no  other  dressings  than  such  as  were  necessary  for 
cleanliness,  and  such  as  each  man  could  easily  perform  for  himself.  They  all,  at 
least  such  as  did  not  stray  away  from  the  command,  had  their  wounds  dressed  at 
Bridgeport,  the  terminus  of  the  ambulance  transportation.  That  their  .wounds 
were  not  afterwards  dressed  by  the  medical  attendants,  was  one  of  those  events, 
unavoidable  in  the  manner  of  the  transportation,  on  a  road  given  up  to  troops  hur- 
rying to  the  front;  and  to  which  end  all  other  movements  were  made  subservient. 
I  can  bear  abundant  testimony  to  the  tLdelity  and  administrative  ability  of  the  ac- 
complished Medical  Director  of  the  department,  as  well  as  to  the  industry  and 
efficiency  of  his  staff.] 


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REPORT  ON  ERYSIPELAS. 


The  following  reports  have  reference  to  the  influence  of 
the  vapor  of  bromine  in  arresting  the  spread  of  erysipelas  in 
Vv'arcls,  and  in  the  treatment  of  cases  of  erysipelas.  For  the 
former,  the  bromine  is  exposed  in  the  wards  in  as  many  places, 
and  in  such  quantity,  as  may  be  found  necessary  to  keep 
the  odor  of  it  constantly  present.  If  the  atmosphere  is  moist, 
the  quantity  required  will  be  proportionally  large.  Thisfumi- 
gaiion  should  be  coniinuedas  long  as  the  sources  of  the  miasm  remain. 

In  treating  cases  of  erysipelas  with  bromine,  the  following 
rules  are  commonly  followed : 

1st.  The  face,  for  example,  being  the  part  aftected,  the  parts 
are  to  be  washed  in  soap  and  water,  so  as  to  remove  all  seba- 
ceous matter,  and  then  sponged  in  clean  water. 

2d.  A  mask  of  patent  lint  is  to  be  prepared,  large  enough 
to  cover  and  extend  three  inches  beyond  the  erysipelatous  area, 
and^n  this  a  j,  shaped  incision  is  to  be  made  for  the  accommo- 
dation of  the  mouth  and  nose. 

3d.     Another  piece  of  lint,  the  exact  counterpart  of  the  first. 

4th.  A  piece  of  oiled  silk  large  enough  to  cover  the  face 
and  head,  with  a  like  j^  incision. 

5th.  Two  pieces  of  lint  large  enough  to  cover  the  eye-lids 
are  to  be  smeared  with  simple  cerate  and  placed  over  the  eyes. 

6th.     The  first  mask  of  lint  is  to  be  placed  over  the  face. 

7tli.  The  second  mask  is  to  be  wetted  in  the  following  so- 
lution : 

Vc — Bromine,  3j. 

Bromide  of  potassium,  gr.  xxx. 
"Water,  3x. — M. 

— and  placed  over  the  first  mask. 


REPORT  ON  ERYSIPELAS. 


The  following  reports  have  reference  to  the  influence  of 
the  vapor  of  bromine  in  arresting  the  spread  of  erysipelas  in 
vrards,  and  in  the  treatment  of  cases  of  erysipelas.  For  the 
former,  the  bromine  is  exposed  in  the  wards  in  as  many  places, 
and  in  such  quantity,  as  may  be  found  necessary  to  keep 
the  odor  of  it  constantly  present.  If  the  atmosphere  is  moist, 
the  quantity  required  will  be  proportionally  large.  This  fumi- 
gation should  be  continued  as  long  as  the  sources  of  the  miasm  remain. 

In  treating  cases  of  erysipelas  with  bromine,  the  following 
rules  are  commonly  followed : 

1st.  The  face,  for  example,  being  the  part  affected,  the  parts 
are  to  be  washed  in  soap  and  water,  so  as  to  remove  all  seba- 
ceous matter,  and  then  sponged  in  clean  water. 

2d.  A  mask  of  patent  lint  is  to  be  prepared,  large  enough 
to  cover  and  extend  three  inches  beyond  the  erysipelatous  area, 
and^n  this  a  j^  shaped  incision  is  to  be  made  for  the  accommo- 
dation of  the  mouth  and  nose. 

3d.     Another  piece  of  lint,  the  exact  counterpart  of  the  first. 

4th.  A  piece  of  oiled  silk  large  enough  to  cover  the  face 
and  head,  with  a  like  j,  incision. 

5th.  Two  pieces  of  lint  large  enough  to  cover  the  eye-lids 
are  to  be  smeared  with  simple  cerate  and  placed  over  the  eyes. 

6th.     The  first  mask  of  lint  is  to  be  placed  over  the  face. 

7th.  The  second  mask  is  to  be  wetted  in  the  following  so- 
lution ; 

9^ — Bromine,  3j. 

Bromide  of  potassium,  gr.  xxx. 
Water,  3x.— M. 

— and  placed  over  the  first  mask. 


82  A   REPORT    OX 

8th.  The  oiled  silk  is  now  to  be  quickly  placed  over  the 
face  and  secured  by  a  roller;  the  object  being  to  cause  the  va- 
por of  the  bromine  to  come  in  a  dry  state  in  contact  with  the 
skin.  Some  surgeons  prefer  the  use  of  the  solution  directly 
upon  the  skin. 

9th.  The  application  should  be  renewed  once  in  four  hours 
until  the  disease  subsides. 

Sometimes  the  above  formula  proves  irritating.  In  that  case 
the  strength  of  the  solution  must  be  reduced  by  the  addition 
of  water. 


I 


Extract  from  a  report  upon  the  use  of  bromine  in  Erysipelas,  by 
B.  Woodward,  Surgeon  '22d  Illinois  Volunteers,  read  before  the 
Louisville  Society  of  Army  Surgeons  : 

^  ^  "  Though  the  society  has  lately  honored  me  by  listen- 
ing to  a  very  imperfect  report  on  bromine,  I  trust  they  will 
pardon  me  if  I  again  allude  to  some  of  the  points  in  that  re- 
port, while  I  add  such  other  testimony  as  I  have  been  able  to 
gain.  While  erysipelas  was  in  every  ward  of  the  Park  Bar- 
racks Hospital,  under  my  charge,  and  one  ward  was  full  of 
erysipelas  patients,  and  from  which  several  died,  I  was  order- 
ed by  Assistant  Medical  Director,  M.  Goldsmith,  to  procure 
bromine,  and  use  its  vapor  in  the  wards  as  a  prophylactic,  and 
watch  its  efiects.  This  I  did,  at  first,  by  dropping  bromine  into 
bottles  and  placing  them  in  the  wards,  and  especially  near  the 
erysipelas  cases.  Although  some  of  these  patients  were  sijk 
from  other  causes,  but  one  died  after  the  bromine  was  used. 

*  *  (He  died  from  acute  oedema  and  sloughing  of  the 
scrotum.)  In  most  of  the  cases  there  was  an  immediate  arrest 
of  the  disease,  and  gradual  in  all.  Not  another  case  originated 
in  the  wards  while  the  bromine  was  used.  *  *  The  ery-. 
sipelas  ward,  which,  for  two  weeks,  had  beeu  filled  with  from 
twelve  to  sixteen  cases  of  the  worst  character,  was  cleaned,  ex- 
cept the  walls,  which  were  of  unplastered  brick,  and  therefore 
eminently  calculated  to  absorb  the  poison ;  and  the  room,  for 


HOSPITAL    GANGRENE,   ERYSIPELAS,    ScC.  83 

forty-eight  hours,  was  kept  full  of  tlie  vapor  of  broraiue,  and 
was  then  used  again  as  a  ward ;  hut  not  a  case  has  occurred 
there.  *  *  Bromine,  like  its  congener,  iodine,  seems 
to  be  antagonistic  to  certain  animal  poisons;  like  chlorine,  it 
is  an  antiseptic;  and  like  both,  it  is  a  catalytic (?).  If  it  is 
objected  tliat  this  is  all  hypothetical,  we  answer  it  is  a  new 
agent.  Its  status  has  never  been  settled,  and  we  have  imper- 
fect data  from  which  to  reason.  The  hypothesis,  then,  is  :  In 
bromine  we  have  an  agent  having  controlling  power  over  cer- 
tain animal  poisons,  equal  to  that  of  iodine,  and  for  certain 
purposes  more  available ;  that  it  lij,as  powers  which  iodine  has 
not  been  proven  to  possess,  viz :  neutralizing  poisons  in  the 
atmosphere;  and  that  for  this  purpose  it  maybe  depended 
upon.  Of  its  constitutional  action  we  know  but  little,  but  it' 
its  present  promise  of  good  holds  true,  its  introduction  into  the 
wards  of  hospitals  will  disarm  them  of  half  their  terrors,  and 
to  military  surgery  it  will  prove  an  inestimable  blessing."     * 


I  can  add  to  Surgeon  Woodward's  statement  the  fact,  that,  at 
the  time  when  I  directed  him  to  procure  and  use  the  bromine, 
the  barracks  were  producing  from  ten  to  twenty-five  cases  of 
erysipelas  per  week ;  and  the  cases  were  of  terrible  severity, 
more  than  fifty  per  cent,  proving  fatal.  No  change  was  made 
in  the  number  of  beds  or  inmates,  no  change  in  the  ventila- 
tion, and  after  the  lapse  of  twenty-four  hours  no  more  cases 
occurred,  nor  did  any  ever  occur,  until  by  some  reason  the 
supply  of  bromine  was  exhausted,  and  then  a  few  cases  only, 
but  the  recurrences  were  again  arrested  by  the  use  of  the  bro- 
mine. 

During  the  early  part  of  the  spring  of  1862,  a  great  many 
cases  of  erysipelas  occurred  at  the  small-pox  hospital  then  in 
charge  of  my  brother,  A.  A.  Surg.  W.  W.  Goldsmith.  Almost 
every  inmate,  nurse  as  well  as  patient,  was  attacked.  The 
stench  arising  from  the  cases  of  small-pox,  crowded  in  low 
rooms,  the  utter  impossibility  of  efiicicnt  ventilation,  engen- 
dered their  lec-itimate  results.     In  these  circumstances  I  sug- 


84  A   REPORT    ON 

gested  to  liim  the  use  of  the  vapor  of  bromine  as  a  clisinfectaut. 
It  was  used  immediately,  and  to  the  effect  of  at  once  arresting 
the  spread  of  the  disease.  After  this,  and  during  the  time  he 
continued  in  charge  of  the  hospital,  bromine  was  used  daily 
in  the  wards,  and  no  new  cases  occurred.  During  the  fall 
and  winter,  several  surgeons  in  succession  having  had  charge 
of  the  hospital,  erysipelas  again  broke  out  in  an  epidemic 
form.     The  bromine  was  again  used,  and  with  a  like  result. 

During  the  past  winter  erysipelas  became  epidemic  in  Hos- 
pital No.  16j  Jeffersonville,  Ind.  As  soon  as  the  bromine  was 
])rocured  and  used,  the  disease  disappeared.  These  are  the 
only  occasions  occurring  under  my  immediate  supervision  in 
which  an  opportunity  was  afforded  for  testing  satisfactorily 
the  agency  of  the  bromine  in  vapor  in  destroying  the  miasm 
j)roducing  erysipelas.  Beside  these,  I  have  had  letters  from 
surgeons  serving  at  distant  posts,  who  speak  with  great  confi- 
dence of  the  prophylactic  powers  of  the  vapor.  The  subject 
needs  further  investigation.  The  experiments  necessary  to  test 
the  question  are  few  and  simple.  All  that  is  it  necessary  to  do 
is  to  liberate  so  much  of  the  vapor  of  the  bromine  as  is  suffi- 
cient to  make  its  odor  obvious  in  the  infected  wards,  care  being 
taken  that  the  atmosphere  of  the  wards  is  as  dry  as  possible. 


CASES  OF  ERYSIPELAS. 

The  following  reports  of  cases  of  erysipelas  are  selected 
from  the  records  of  various  hospitals,  mostly  from  those  of 
Hospitals  Nos.  19  and  20,  in  order  to  show  the  usual  course 
of  events  in  the  cases  treated  with  bromine.  Hospitals  l^os. 
19  and  20  were  established  for  the  treatment  of  cases  of  ery- 
sipelas exclusively.  Those  occurring  at  the  other  hospitals 
were  at  once  removed  to  one  or  the  other  of  these ;  and 
almost  all  the  patients  were  subjected  to  a  uniform  course  of 
treatment — that  indicated  on  a  previous  page. 

The  rapidity  with  which  the  disease  was  aborted  prevented 


HOSPITAL   GANGRENE,    ERYSIPELAS,    A-C.  85 

the  development  of  many  grave  symptoms,  and  tended  to  im- 
press the  observer,  as  perhaps  the  record  will  impress  the 
reader,  with  the  idea  that  they  were  trivial  iu  their  violence. 
That  such  impression  does  not  comport  with  the  facts  will  be 
seen  by  the  statement,  that  just  at  those  periods  when  all  the 
cases  in  the  erysipelas  hospitals  were  apparently  so  mild,  the 
patients  who,  by  any  accident,  were  delayed  for  a  few  days  in 
their  removal  to  these  hospitals,  presented,  on  their  arrival,  all 
the  severities  commonly  belonging  to  grave  erysipelas  of  the 
head  and  face. 


I  was  called  out  of  hospital  to  see  a  gentleman  in  a  private 
dwelling,  who  was  the  subject  of  erysipelatous  inflammation. 

This  gentleman  was  born  in  the  State  of  Vermont;  at  eight 
years  of  age  emigrated  to  Ohio,  and  grew  up  there  to  man- 
hood, then  emigrated  to  Illinois,  where  he  resided  before  leav- 
ing for  Kashville,  Tenn.,  to  which  place  he  was  going  when 
he  took  sick,  and  not  being  able  to  travel  further,  he  stopped 
in  this  city;  has  had  numerous  a.ttacks  of  intermittent  fever; 
is  now  56  years  of  age.     I  saw  him  first  on  the  13th  inst. 

Face  tumefied  to  the  extent  of  closing  both  eyes ;  skin  red, 
with  large  bulli?e;  inflammation  commenced  upon  the  nose,  ex- 
tended upwards  and  downwards,  and  spread  laterally  over  the 
entire  face,  neck,  and  scalp  ;  skin  between  the  numerous  bul- 
lae felt  like  the  grain  side  of  upper  leather ;  bullge  filled  with 
dark  yellow  fluid ;  severe  cephalalgia;  says  it  feels  like  burst- 
ing open ;  pulse  beats  100  per  minute,  and  feeble ;  bowels  cos- 
tive; urine  scanty  and  high  colored;  no  abnormal  appearance 
elsewhere  upon  the  body;  intellect  unimpaired;  appetite 
poor;  great  thirst;  no  abnormal  sounds  of  heart  or  lungs. 

TREATMENT. 

Quinine,  gr.  ij.,  every  four  hours,  in  3j.  whisky.  Local  ap- 
plications— Bromine  10  drops  to  3j.  alcohol — applied  as  direct- 
ed by  Dr.  Woodward. 

December  14th.  Ten  hours  after  first  visit,  l^o  discoverable 
change;  appliances  moistened  again — alcohol  3j.,  10  drops 
bromine. 


8G  A   REPORT    ON 

Third  visit,  ten  hours  afterwards,  same  da}-.  Still  no  appre- 
ciable alterations,  except  that  the  inflammation  had  ceased  to 
spread.  Internal  treatment,  in  addition  to  quinine  and  whis- 
ky, 12  drops  of  tincture  of  opium,  and  3  drops  tine,  verat.  virid., 
to  be  given  every  four  hours. 

December  15th.  Twelve  hours  intervening  since  last  visit. 
Patient  much  better;  says  he  feels  like  a  new  man;  pulse  60 
beats  per  minute ;  tongue  clammy ;  no  cephalalgia ;  skin  moist ; 
bowels  costive ;  has  not  had  an  operation  since  he  left  Indian- 
apolis; tumefaction  of  face,  scalp,  and  neck  almost  entirely 
subsided;  can  now  open  his  eyes;  no  fluid  discoverable  in  bul- 
lifi ;  redness  of  skin  entirely  subsided.  Treatment  with  bro- 
mine as  before  ;  discontinue  laudanum  and  veratrum  viride. 
One  ounce  of  salts ;  continue  quinine  and  whisky. 

Same  day,  ten  hours  since  former  visit.  Bowels  have  ope- 
rated freely ;  patient  still  improving ;  pulse  now  70.  Ordered 
laudanum  and  veratrum  as  before;  continue  quinine  and  whis- 
ky; apply  bromine  as  before. 

December  16th.  Fourteen  hours  since  last  visit.  Pulse  58 
beats  per  minute,  full  and  soft;  skin  soft  and  moist;  tongue 
clear,  skin  covering  inflamed  surface  assuming  its  normal  ap- 
pearance, except  that  part  occupied  by  bullse^  the  cuticle  of 
which  looks  white  and  lies  loose  upon  the  true  skin.  Contin- 
ued quinine  and  whisky  ;  continued,  also,  laudanum  and  verat- 
rum; discontinued  bromine. 

December  17th.  Patient  still  improving ;  says  he  feels  able 
to  start  home ;  continue  treatment. 

December  18th.  Patient  fully  convalescent,  and  treatment 
discontinued,  except  such  covering  as  is  necessary  to  exclude 
the  air  an^l  keep  the  parts  comfortably  warm.  I  dismissed  this 
case  to  day  cured,  and  he  is  now  on  his  way  home.  This  was 
a  severe  case  of  erysipelas,  and  much  might  be  said  in  favor 
of  the  influence  exerted  by  the  bromine  in  the  case ;  but  at 
present  I  will  not  speak  of  its  virtues,  as  I  wish  to  make  fur- 
ther testa  of  its  ability  to  meet  and  destroy  poison. 

R.  L.  STANFORD,  Surgeon  U.  S.  V, 


HOSPITAL    GANGRENE,    ERYSIPELAS,    iC.  87 

Case  of  Erysipelas  successfully/  treated  with  bromine. 

Henry  H.  Bollis,  aged  22,  private  company  F,  18th  Oliio, 
enlisted  September  17th,  1861 ;  places  of  service,  Mississippi, 
Alabama,  and  Tennessee. 

Previous  IIisior>/. — He  has  been  sick  for  several  months  pre- 
vioi>s  to  admission  into  Hospital  Ko.  8,  suiFering  from  general 
debility,  with  great  disorder  of  the  digestive  organs. 

Present  Condition. — Admitted  into  Hospital  No.  8  on  the  13th 
of  March,  1863.  The  patient  is  somewhat  emaciated,  and  very 
feeble.  He  looks  quite  exsanguious,  and  complained  of  wan- 
dering pains  throughout  the  whole  body;  he  has  no  appetite ; 
his  bowels  are  irregular,  at  present  constipated.  His  pulse  is 
98  to  the  minute,  small  and  irregular ;  his  tongue  is  coated 
with  thick  white  epithelium,  but  quite  moist;  a  large  elevated 
blotch,  decidedly  erysipelatous  in  character,  is  seen  on  the 
right  cheek  and  extending  over  the  right  side  of  the  forehead, 
and  also  involves  the  right  ear  and  a  portion  of  the  scalp. 

Treatment. — Saline  purgatives  were  administered  daily,  so  as 
to  effect,  at  least,  one  full  passage  per  diem.  Bromine  was 
kept  constantly  evaporating  in  the  ward,  so  that  its  character- 
istic odor  was  always  distinctly  perceptible.  The  local  admin- 
istration of  bromine  was  resorted  to  from  the  beginning;  and 
the  following  prescription  exhibited : 

9^ — Bromine  gtt.  ix. 

Glycerine,  5j.  ss. 

M. 
Two  teaspoonsful  to  be  taken  every  four  hours.  This  gives  one 
and  a-half  drops  to  the  dose.  "Within  twenty-four  hours  (the 
local  application  of  bromine  having  been  renewed  twice  during 
that  time)  the  disease  was  arrested,  and  a  marked  improvement 
in  the  constitutional  symptoms  was  also  observed.  The  patient 
continued  to  improve  steadily,  and  had  entirely  recovered  on 
the  16th  inst.,  when  the  internal  administration  of  bromine 
was  stopped.  The  air  in  the  ward  was  still  kept  heavily  im- 
pregnated with  the  vapor  of  bromine  until  the  18th  inst.  This 
was  done  to  prevent  the  possibility  of  the  recurrence  of  the 


88  A   REPORT   ON 

disease,  this  having  taken  place  in  two  instances,  when  the 
use  of  the  vapor  of  bromine  was  discontinued  at  too  early  a 
period.  J.  A.  OCTERLO^Y,  A.  A.  S.  U.  S.  A, 


[The  following  cases,  reported  from  Hospital  No.  19,  were 
recorded  by  Mr.  Palmer,  Medical  Cadet.] 

"William ,  company  E,  31st  Ohio,  age  38,  admitted 

March  26th,  1863,  to  Hospital  No.  19,  Ward  2. 

Symptoms  on  Admission. — Been  sick  seven  months,  had  had 
chronic  diarrhea  four  months,  and  during  the  whole  seven 
months  had  dyspepsia;  great  tenderness  over  abdomen  and 
epigastrium,  existing  for  six  months;  evidently  has  chronic 
inflammation  of  stomach  and  intestines;  he  has  vomited  a 
good  deal  after  taking  food ;  appetite  poor,  but  asks  for  fresh 
beef  and  milk ;  erysipelas  extending  from  median  line  of  nose 
up  to  eye-brow,  below  angle  of  jaw  posteriorly  to  ear — all 
on  left  side ;  no  nervous  symptoms,  but  somewhat  emaciated, 
and  very  weak ;  urine  normal,  bowels  quite  loose,  pain  in  re- 
gion of  kidneys.  Apply  bromine  to  diseased  parts.  Pr — opii. 
pulv.,  grs.  ss.,  at  night. 

March  27th.  Sixteen  hours  from  first  application  of  bro- 
mine the  erysipelas  was  arrested ;  pulse  75 ;  symptoms  gener- 
ally better ;  continue  bromine  to  face.  5r — Wine,  tablespoon- 
fal  every  two  hours. 

March  28th.  Erysipelas  subsiding  fast ;  has  slight  diarrhea ; 
one  more  application  of  bromine.  V^ — Pul.  opii,  grs.  ss.,  after 
every  discharge. 

March  29th.  Erysipelas  gone ;  other  symptoms  somewhat 
improved.     To  drink  one  bottle  porter  to  day. 

March  30th.     Convalescent. 

General  Hospital,  No.  19., ) 
January  6th,  1863.      j 

Ebenezer  McDonald,  tet.  33,  private,  co.  I,  87th  Indiana 
Vols.,  was  admitted  to  Ward  No.  4,  Hospital  19.     On  admis- 


HOSPITAL   GAXCIRENE,    ERYSIPELAS,    &C.  89 

sioii  be  had  erysipelas  of  tlio  face,  ou  left  side,  extending  from 
median  line  to  occiput,  above  to  frontal  suture,  and  below  to 
angle  of  jaw;  pulse  74,  feeble;  skin  soft,  perspiring;  tender- 
ness on  pressure  over  abdomen;  bowels  torpid;  icterus  well 
marked  ;  scalding  sensation  on  micturition ;  rested  poorly ;  ra- 
tional, and  no  nervous  symptoms ;  face  livid,  slight  fur  on 
tongue,  sordes  on^  teeth  and  gums,  urine  high  colored. 

Treatment — Bromine,  gtt.  xx.,  alcohol  3j.,  applied  externally, 
in  vapor ;  bromine,  gtt.  one-half,  internally,  every  four  hours. 

Jan.  7th.  Face  pale,  pulse  natural,  teeth  cleaning,  abdo- 
men less  tender,  urine  more  natural ;  continue  treatment. 

Jan.  8th.  Erj^sipelas  nearly  all  gone ;  skin  natural,  teeth 
cleaning,  less  pain  in  micturition,  urine  nearly  normal.  Stop 
bromine  and  give  quinine  and  whisky. 

Jan.  9th.  Erysipelas  gone;  icterus  has  gradually  subsided 
from  the  beginning  of  treatment ;  abdomen  free  from  tender- 
ness; pulse  natural;  pain  in  micturition  gone.  Discharged 
from  service  February  25th,  1863. 

Daniel  Russell,  set.  30,  private  co.  II,  14th  Michigan  Vols., 
nurse ;  attacked  March  2d  with  dipjitheria,  with  slight  fever ; 
pulse  75,  full;  skin  moist  and  warm,  tongue  slightly  coated, 
bowels  regular,  urine  normal.  To-day  nitrate  of  silver,  grs.  x. 
to  3j.  of  water,  was  used  as  a  cautery  in  throat,  to  take  gtt.  x. 
every  four  hours  of  tinct.  ferri  mur.,  with  saturated  solution 
of  chlorate  of  potassa  ad  libitum.  No  swelling  existed  to-day 
in  throat. 

March  3d.  To-day  solution  of  nitrate  of  silver  grs.  xxx.  to 
3j.  water,  used  three  times;  continued  iron  and  chlorate  of  po- 
tassa; swelling  beginning  to  manifest  itself;  symptoms  gener- 
ally same  as  yesterday. 

March  4th.  Swelling  continued ;  same  treatment  continued. 
To-day  erysipelas  has  manifested  itself  on  left  cheek,  extend- 
ing from  medium  line  of  nose,  and  one-half  inch  below  zygo- 
matic process  up  to  scalp.  Bromine,  gtts.  xl.,  in  saturated  so- 
lution, of  chlorate  of  potassa,  was  applied  in  vapor. 


90  A   REPORT   ON 

Marcli  5tli.  Erysipelas  liad.not  spread  any,  but  is  literally 
killed.  The  bromine  was  applied  yesterday  and  during  last 
niglit  only  twice ;  one  more  application  ordered  to-day,  and 
other  treatment  continued. 

March  6th.  Bromine  stopped  ;  other  treatment  still  contin- 
ued, except  the  nitrate  of  silver.  This  treatment,  viz  :  iron 
and  chlorate  of  potassa,  was  continued  for  several  days,  and  to- 
day, ]\Iarch  11th,  the  patient  is  convalescent. 

Milo  Butler,  co.  I,  85th  111.,  fct.  29,  admitted  April  7th,  1863. 

Symptoms  on  Admission.  Eight  days  ago  commencd  to  con- 
valesce from  small-pox.  Erysipelas  began  five  days  ago.  It 
involves  the  whole  right  side  of  the  face;  aphonia  exists; 
functions  normal.  Bromine  applied  in  vapor.  Jh — Tinct.  fer- 
ri  mur.,  gtt.  x.,  every  two  hours. 

April  8th.     Erysipelas  arrested.     Continue  treatment. 

April  9th.  Erysipelas  gone.  Stop  treatment  above,  and 
give  cinchonse  sulph.  and  whisky  every  four  hours. 

April  10th.     Sulph.  cinchona  and  whisky  every  four  hours. 

April  11th.     Convalescent. 


Case  of  Erysipelas  successfully  treated  with  bromine. 

William  Lisenby,  cet.  37,  private,  co.  E,  80th  Illinois  Vols., 
enlisted  early  in  July  last.  Place  of  service,  Kentucky  and 
Tennessee. 

Previous  History. — He  has  enjoyed  good  health  since  he  en- 
tered the  army,  until,  some  weeks  previous  to  his  admission 
into  Hospital  No.  8,  he  was  taken  severely  ill  with  pneumonia, 
which  reduced  his  strength  extremely. 

Present  Condition. — This  patient,  admitted  into  General  Hos- 
pital No.  8  on  the  13th  day  of  March,  1863,  is  found  to  be 
very  much  reduced  ;  quite  anaemic,  with  a  low  and  irregular 
pulse,  his  tongue  moist,  pale,  and  flabby ;  he  complains  of 
having  had  no  passage  for  several  days  ;  he  suffers  severe  pain 
in  his  right  ear,  which  is  red  and  swollen  :  the  meatus  audito- 


HOSPITAL    GANGRENE,    ERYSIPELAS,    &G      '  01 

rous  externus  is  nearly  closed,  and  the  patient  was  supposed 
to  have  otitis.  Emollient  applications  were  ordered,  and 
seemed  to  relieve  the  pain,  although  the  swelling  had  in- 
creased somewhat,  when  the  patient  was  seen  in  the  evening, 
March  14th,  1863.  On  removing  the  poultice  the  swelling  is 
found  to  have  extended  over  the  right  side  of  the  face,  com- 
pletely closing  the  eye  of  that  side  ;  the  swelling  also  involved 
a  portion  of  the  scalp  and  forehead.  The  poultice  was  at 
once  removed,  and  the  local  application  of  bromine  substituted 
for  it.  The  patient  was  constantly  exposed  to  the  vapor  of 
bromine  with  which  the  air  in  the  ward  was  continually  im- 
pregnated; one  and  a  half  drops  of  bromine  to  3ij.  of  glycerine 
given  every  four  hours.  The  progress  of  the  disease  was  arrest- 
ed within  thirty-six  hours.  The  remedies  were  used  as  above 
stated  until  the  19th  inst.,  when  the  patient  was  pronounced 
to  be  entirely  recovered  from  the  attack  of  erysipelas,  though 
still  weak  and  troubled  with  a  cough  and  pain  in  his  left  side, 
probably  the  relics  of  the  pneumonia  under  which  he  labored 
previous  to  his  admission;  his  appetite  is  good,  and  he  is 
rapidly  progressing  towards  perfect  health. 


[  The  following  is  inserted  to  illustrate  an  occurrence  fre- 
quently observed  in  the  cases  in  which  iodine  had  been  ap- 
plied in  the  early  treatment.  The  iodine,  as  is  well  known, 
causes  the  dessication  of  a  layer  of  epithelium,  which,  while  it 
remains  adherent,  forms  a  coating  efficient  to  the  protection  of 
the  sensitive  parts  beneath.  Such  a  covering  is  a  complete 
barrier  to  the  efficacious  application  of  the  bromine.  In 
cases  of  this  sort  it  was  always  found  necessary  to  detach  this 
hardened  epithelium  before  the  bromine  could  be  applied  to 
any  useful  result.] 

E.  M.  Bradley,  private,  co.  K,  91st  Illinois,  jet.  20  years, 
was  admitted  December  4th  to  Hospital  No.  12,  Ward  2,  Bed 
No.  33. 

History. — Was  born  in  Massachusetts ;  lived  in  Vermont  un- 


92  '  A   REPORT   ON 

til  twelve  years  of  age,  since  wlien  lie  has  lived  in  Illinois. 
He  was  attacked  witli  diarrhea  ten  weeks  since,  followed  with 
chills,  which  was  the  fore-runner  of  bilious  fever ;  was  sick  at 
that  time  eight  weeks.  He  was  moved  from  near  Lebanon 
Junction  to  Hospital  No.  12,  in  this  city,  December  4th,  with 
diarrhea,  which  he  had  more  or  less  for  the  whole  time  ;  was 
well  previous  to  enlisting ;  was  sworn  into  the  U.  S.  service 
September  8th,  1862. 

Present  State. — December  llth,  1862.  There  has  been  noth- 
ing unusual  in  this  case  until  to-day;  his  diarrhea  has  yielded 
kindly  to  astringents,  &c. 

To-day  I  find  his  face  swollen  full  (unable  to  open  either 
eye),  red  and  shining,  very  painful  on  pressure ;  slight  diarrhea. 
Diagnosis :  erysipelas. 

December  llth.  Face,  cheeks,  and  lips  are  very  much 
swollen ;  do  not  pit  on  pressure,  but  have  the  feeling  peculiar 
to  erysipelas ;  skin  dry ;  pulse  95  per  minute — beats  full  and 
strong ;  tongue — edges  red,  light  coating  through  the  center ; 
intellect  and  nervous  system  normal.  The  swelling  extends  to 
the  forehead,  nearly  to  the  hair,  and  is  exceedingly  tender ; 
abdomen — slight  tenderne^  on  pressure;  urine  scanty  and 
high  colored. 

Frescription,  Diet,  <|^c. — "Whisky,  half  ounce,  quinine  two 
grains,  every  four  hours.  Paint  surface  for  two  inches  beyond 
inflamed  surfoce  with  tr.  iodine.     Extra  diet. 

December  12th. — Cheeks  and  lips  more  swollen;  can  not 
see  with  either  eye ;  skin  dry ;  pulse  100 ;  tongue  red,  coating 
through  center  darker  than  yesterday ;  restlessness ;  the  swell- 
ing has  extended  into  the  scalp,  pits  on  pressure,  great  tender- 
ness ;  abdomen  less  tender  than  yesterday ;  urine  more  abun- 
dant. 

Prescription,  Diet,  ^-c. — Continue  whisky  and  quinine;  re- 
move hair  and  whiskers;  paint  whole  head  with  tr.  iodine; 
five  grains  Dover's  powder  at  night. 

December  13th.  Swelling  increased,  more  painful  than  yes- 
terday; skin  dry;  pulse  100;   tongue,  edges  darker  and  red- 


HOSPITAL   GANGRENE,   ERYSIPELAS,   &C.  93 

der  tliau  yesterday;  more  restlessness;  swelling  and  tumefac- 
tion spreading  to  whole  scalp;  slight  diarrhea;  urine  normal. 

Prescription,  Diet,  j|^c.— Omit  tr.  iodine ;  apply  bromine ;  con- 
tinue whisky  and  quinine ;  give  tinct.  opium,  IG  drops,  tr. 
veratrum  viride,  4  drops,  every  six  hours,  to  check  diarrhea. 

December  14th.  Face,  cheeks,  and  lips— swelling  cxtend- 
ino-;  skin  dry;  pulse  85;  tongue  moist  and  dark;  sleeps  bet- 
ter ;  no  change.  The  skin  is  covered  with  cuticle  hardened  hy  tr. 
iodine;  less  diarrhea;  urine  normal.  Remove  cuticle,  which 
tears  off  easily.     Continue  treatment. 

December  15th.  Face,  cheeks,  lips— swelling  less,  can  see 
from  left  eye ;  skin  moist ;  pulse  80 ;  tongue  moist  and  lighter 
than  yesterday ;  intellect  normal ;  less  swelling  and  pain ;  ab- 
domen and  urine  normal.     Continue  treatment. 

December  16th.  Less  tumefaction  of  face 'and  cheeks ;  skin 
moist;  pulse  80  ;  tongue  cleaning;  intellect  normal ;  swelling 
and  tenderness  nearly  gone;  sloughing  of  right  upper  side; 
abdomen  and  urine  normal.  Omit  bromine,  tr.  opii,  and  ve- 
ratrum viride.     Continue  whisk}-  and  quinine. 

December  19th.  Face,  cheeks,  and  lips — slight  tumefaction ; 
skin  moist ;  pulse  80  ;  tongue  clean ;  intellect  normal ;  abscess 
in  left  upper  and  right  under  eye-lid ;  abdomen  and  urine  nor- 
mal. Continue  whisky  and  quinine ;  open  abscesses ;  apply 
poultices. 

December  21st.  No  tumefaction  except  above  eye-lid ;  skin 
moist;  pulse  80 ;  tongue  clean;  intellect  normal ;  ulcerations 
and  abcesses  about^yes  filling  up  with  healthy  gi-anulations  ; 
abdomen  and  urine  normal.     Continue  treatment. 

December  25th.  Face,  cheeks,  and  lips  natural ;  skin  moist ; 
pulse  76 ;  tongue  clean  ;  intellect  normal ;  ulcerations  nearly 
filled ;  abdomen  and  urine  normal.  Omit  all  treatment  except 
extra  diet. 


The  consolidated  tabular  statement  of  the  cases  of  erysipe- 
las, treated  at  this  place,  is  annexed.  My  own  observation  of 
the  cases  convinced  me  that  the  earlier  cases,  those  treated 


t)4  A   REPORT   ON 

before  the  adoption  of  the  bromine,  were  mucli  more  severe 
than  those  occurring  at  later  dates.  Still  every  case  recorded 
was  one  of  well  marked  and  genuine  erysipelas.  The  roll  of 
these  cases,  and  the  detailed  records,  are  in  the  Surgeon  Gen- 
eral's office. 

In  conclusion,  I  beg  leave  to  state  that  none  of  the  cases 
of  hospital  gangrene  or  of  erysipelas,  the  records  of  which  are 
given  here,  or  have  been  heretofore  forwarded  to  the  Sur- 
geon General's  office,  were  treated  by  me.  The  results  here 
presented  are  those  arrived  at  in  the  practice  of  some  sixty 
medical  officers  stationed  at  this  and  at  some  distant  points. 
Those  serving  here  were  under  my  immediate  supervision. 
Those  at  other  points  had,  many  of  them,  but  an  imper- 
fect acquaintance  with  the  reasoning  upon  which  the  treat- 
ment was  based";  nor  were  they  acquainted,  many  of  them, 
fully  with  the  clinical  measures  necessary  for  the  most  effi- 
cacious application  of  the  bromine.  My  own  views  on  this 
point  were  not  sufficiently  set  forth  in  the  circular  issued  in 
the  beginning  of  these  investigations ;  nor  had  I  then  defi- 
nitely determined  in  my  own  mind  the  points  which  I  have 
striven  to  enforce  in  the  foregoing  pages. 

As  the  measure  of  the  value  of  a  remedy  is,  in  some  sense, 
in  its  working  value,  not  to  be  determined  so  much  by  its 
eifects  in  the  hands  of  gifted  experts  as  in  the  hands  of  the 
generality,  so  to  speak,  the  average  of  practitioners,  I  have 
preferred  to  present,  for  the  consideration  of  the  Surgeon  Gen- 
eral, such  records  as  would  exemplify  ^e  aggregate  of  the 
observations  thus  far  made. 

I  beg,  also,  to  remind  the  Surgeon  General  that  the  results 
thus  far  reached  are  results  had  with  a  new  remedial  agent, 
the  rules  for  the  use  of  which  had  to  be  worked  out  in  the 
midst  of  many  difficulties,  not  the  least  of  these  being  the  tra- 
ditional indisposition  to  abandon  the  tried  resources  of  medi- 
cine in  favor  of  new  agents  based  upon  views  not  in  exact 
accordance  with  accredited  dogmata. 

I  have  the  honor  to  be,  your  obedient  servant, 

M.  GOLDSMITH,  Surgeon,  U.  S.  V, 


o"?   5'  -«   o   <i 

'^  =i- "  °  i"  £ 

-,  h,  -1  -    -• 


I- 


I? 

o  • 


Number  of  cases. 


Diphthe 


Suppuration  of  the  cellular  tissue. 


Typhus. 


1  (Edema  Glottidis. 


Chronic  Diarrhea. 


Gangrene  of  the  tongue. 


iSecondary  Syphilis. 


Chronic  bronchitis. 


><^  »— 


00        Uncomplicated. 


{'Gangrene  of  the  1 


Typhoid  pneumonia. 


(Edema  Glottidis. 


tr  a.      —(a- 
op      5^  P 


d         Its  !^^  5' 


•srosgocD" 


izi'^i 


on    LC 


►s  s  s- 


5* 


Secondary  hemorrhage. 


Uncomplicated. 


Average  date  at  which  the  spread 
sipclas  was  arrested. 


of  ery- 


Averagc  date   at  -which  the  erysipel 
appears. 


Average  date  of  conyalescence. 


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